MEDICAL 


THE 


STUDENT'S  GUIDE 


SURGICAL    ANATOMY 


BEING  A  DESCRIPTION  OF  THE  MOST  IMPORTANT  SURGICAL 

REGIONS  OF  THE  HUMAN  BODY,  AND  INTENDED 

AS  AN  INTRODUCTION  TO 

OPERATIVE  SURGERY. 


BY 

EDWARD   BELLAMY,   F.R.C.S., 

ASSOCIATE    OF    KING'S    COLLEGE,   LONDON;    SENIOR  ASSISTANT-SURGEON  TO    THE 

CHARING    CROSS   HOSPITAL;    SURGEON    TO    THE    ROYAL    INFIRMARY    FOK 

CHILDREN,  WATERLOO  ROAD;   AND  TEACHER   OF  OPERATIVE 

SURGERY  IN  THE  MEDICAL  SCHOOL  OF   CHARING 

CROSS  HOSPITAL. 

WITH   ILLUSTRATIONS. 


PHILADELPHIA: 
H    E    N    R    Y      0.      LEA. 

1874. 


SHERMAN  A  CO.,   PRINTERS, 


•      /.     •*»,      *  *!>H,lL\DEiPHCA          •      • 


B43 
1874 


TO 

JOHN  WOOD,  ESQ.,  F.R.S., 

PROFESSOR  OF  SURGERY  IN  KING'S  COLLEGE,  LONDON, 

THIS  SMALL  VOLUME 

is 
INSCRIBED 

BY     HIS     FORMER     PUPIL, 

THE  AUTHOR. 


PEEFACE. 


A  CONSIDERABLE  experience  as  a  teacher  has  con- 
vinced me  that  there  is  room  for  a  small  work  on  what 
might  be  termed  Applied  Anatomy.  With  the  excep- 
tion of  my  friend  Mr.  Galton's  translation  of  Professor 
Roser's  work,  there  is  no  English  handbook  of  the  kind 
within  the  reach  of  the  generality  of  students. 

Pupils  are  apt  to  lay  aside  their  anatomical  studies 
after  having  passed  their  primary  examination,  and  to 
be  confused  at  finding  a  considerable  amount  of  Surgi- 
cal Anatomy  required  of  them  when  they  present  them- 
selves for  their  final  or  pass. 

With  a  view  of  assisting  them,  this  work  has  been 
prepared.  A  knowledge  of  Descriptive  Anatomy  is 
presupposed,  and  such  regions  of  the  body  as  do  not 
seem  to  bear  directly  upon  the  operative  or  more  practi- 
cal parts  of  Surgery,  have  been  either  merely  referred  to 
or  entirely  omitted. 

I  do  not  hesitate  to  state  that  I  have  in  one  or  two 
instances  availed  myself  of  methods  of  arrangement 
adopted  by  others ;  yet  all  the  statements  have  been 

415 


VI  PREFACE. 

confirmed  by  actual  demonstration,  and  may  be  regarded 
as  an  embodiment  of  the  remarks  made  to  students  at- 
tending my  course  of  Operative  Surgery  at  Charing 
Cross  Hospital. 

The  engravings  are,  in  some  instances,  borrowed  by 
permission  from  Mr.  Heath's  excellent  work  on  Practi- 
cal Anatomy,  or  have  been  drawn  upon  wood  by  myself, 
Mr.  Wesley,  and  Mr.  Sherwin,  from  nature,  or  have 
been  adapted  from  such  sources  as  will  be  found  ac- 
knowledged in  their  proper  places. 

I  have  to  express  my  obligation  to  my  friend  Dr. 
James  Cantlie,  M.  A.,  M.  C.,  Demonstrator  of  Anatomy 
at  Charing  Cross  Hospital,  for  his  kindness  in  revising 
the  proofs,  and  for  other  valuable  assistance. 

EDWARD  BELLAMY. 

MARGARET  STREET,  CAVENDISH  SQUARE, 
October,  1873. 


CONTENTS. 


PAGE 

INTRODUCTION,       .        .        .        .        .        .        .        .        .11 


CHAPTER  I. 
SURGICAL  ANATOMY  or  THE  HEAD,    .        .        .         .        .13 

CHAPTER  II. 
SURGICAL  ANATOMY  or  THE  NECK, 66 

CHAPTER    III. 
SURGICAL  ANATOMY  or  THE  THORAX,        ....     106 

CHAPTER  IV. 

SURGICAL  ANATOMY  or  THE  UPPER  EXTREMITY,      .        .     121 

CHAPTER  V. 

SURGICAL  ANATOMY  or  THE  ABDOMEN,      .        .        .        .168 
SURGICAL  ANATOMY  OF  THE  PELVIS,          .        .        .        .     190 

CHAPTER  VI. 

SURGICAL  ANATOMY  OF  THE  LOWER  EXTREMITY,     .        .     230 


EKRATA. 

Page  82,  line  10  from  top,  the  sentence  should  read  thus :  "  The 
pulsations  of  the  vessel  are  in  reality  felt  beneath  its  anterior  bor- 
der," &c. 

Page  89,  first  line,  for  "  superjacent  "  read  "subjacent." 
Page  90,  12  lines  from  bottom,  for  "  process  "  read  "  artery." 


LIST   OF    ILLUSTRATIONS. 


FIG.  PAGE 

1.  Diagram  of  the  structures  to  be  avoided  in  using  the  tre- 

phine.    Drawn  by  Author, 19 

2.  Vertical  section  of  nasal  fossae  and  pharynx,  &c.     Drawn 

by  Author,     .         .         . 30 

3.  Lachrymal  apparatus  and  nasal  duct.     Drawn  by  Author ,  38 

4.  Aponeuroses  of  orbit.     Drawn  by  Author,         ...  42 

5.  Defective  development  of  superior  maxilla.     Fergusson,  46 

6.  "                   "                       «                "             Fergusson,  46 

7.  "                  "                      "               "            Fergusson,  46 

8.  Dissection  of  soft  palate.     Fergusson,       ....  50 

9.  Kelations  of  tonsil,  lateral  view.     Drawn  by  Author,       .  52 

10.  "               "         from  above.     Drawn  by  Author,        .  53 

11.  Deep  relations  of  parotid.     Drawn  by  Author,          .         .  55 

12.  Lingual  artery  and  branches.     Heath,     ....  62 

13.  Diagram  of  parts  seen  in  a  horizontal  section  of,  neck  at 

sixth  cervical  vertebra.     Drawn  by  Author,         .         .  83 

14.  Common  carotid  artery  and  branches.     Richet,         .         .  89 

15.  Vertical  section  of  thorax  through  clavicle  and  relations 

of  subclavian  vessels.     Drawn  by  Author,   ...  94 

16.  Eegion  of  third  part  of  subclavian  artery.     Adapted  from 

Blandin,        .........  96 

17.  Section  through  superior  aperture  of  thorax.     Heath,     .  105 

18.  Relations  of  thoracic  viscera  to  walls  of  chest.     Altered 

from  Beaunis  and  Bouchard,         .         .         .         .         .108 

19.  Parts  beneath  deltoid.     Altered  from  Anger,    .         .         .  124 

20.  Diagrammatic   section   of    shoulder-joint.       Drawn   by 

Author, 127 

21.  Ligature  of  third  part  of  axillary  artery.     Drawn  by 

Author, 139 

22.  Section  through  middle  of  upper  arm.     Heath,         .         .  142 


X  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

23.  Structures  in  relation  with  anterior  aspect  of  elbow-joint. 

Altered  from  Anger,      .         .         .         .         .         .         .149 

24.  Section  through  middle  of  forearm.     Heath,    .         .         .  153 

25.  Superficial  dissection  of  inguinal  and  femoral  regions. 

Wood, 174 

26.  Dissection  of  lower  part  of  abdominal  wall  from  within. 

Wood, 177 

27.  Dissection  of  inguinal  canal.      Wood,        ....  179 

28.  Diagram  of  congenital  hernia.     Heath,    ....  180 

29.  "  infantile          "         Heath,     .         .         .         .180 

30.  Crural  sheath,  laid  open.      Wood, 185 

31.  Section  of  structures  passing  beneath  Poupart's  ligament. 

Wilson, 186 

32.  Irregular  course  of  obturator  artery.     Drawn  by  Author 

after  Gray, 187 

33.  Sketch  of  artificial  anus.     Drawn  by  Author,  .         .         .  188 

34.  Arrangement  of  lumbar  fascia  at  third  lumbar  vertebra. 

Drawn  by  Author,          .......  195 

35.  Tissues  forming  scrotum.     Drawn  by  Author,  .         .         .  198 
36    Section  of  pelvis,  in  median  plane.     Heath,     .         .         .  213 

37.  Deep  dissection  of  perineum.     Richet,      ....  215 

38.  Longitudinal  section  of  bladder,  penis,  &c.      Wilson,       .  218 

39.  Transverse  section  of  pelvis  from  behind.      Wilson,          .  224 

40.  Superficial  dissection  in  front  of  thigh.     Heath,       .         .  234 

41.  Section  through  hip  and  gluteal  region.    Drawn  by  Author 

after  Beraud, 245 

42.  Section  of  thigh  in  Scarpa's  space.     Heath,     .         .         .  251 

43.  Deep  dissection  of  the  popliteal  space.     Heath,         .         .  258 

44.  Knee-joint  opened  vertically.     Drawn  by  Author  after 

Beraud, 262 

45.  Horizontal  section  through  knee-joint.    Drawn  by  Author,  264 

46.  Section  of  leg  in  upper  third.     Heath,      ....  268 

47.  .Relation  of  parts  behind  inner  malleolus      Heath,  .         .  273 

48.  Section  through  ankle-joint.     Heath,        ....  278 

49.  Sketch  of  parts  removed  in  operations  on  foot.     Drawn 

by  Author, 283 

50.  Skeleton  of  foot  showing  the  articulations  at  which  the 

various  amputations  are  performed.    Drawn  by  Author,  285 


INTRODUCTION. 


As  the  subject  of  Regional  Surgery  and  Surgical 
Anatomy  bears  directly  upon  Operative  Surgery,  it  may 
not  be  considered  out  of  place  to  remind  the  student  of 
the  necessity  of  making  most  careful  inspection  of  the 
body  as  a  whole  before  he  attempts  the  more  minute 
and  detailed  examination  of  its  various  parts.  For  this 
purpose  both  the  living  model  and  the  dead  subject 
should  be  examined  together.  For  such  examination 
the  body  should  be  lying  down — in  fact,  in  the  position 
a  patient  would  be  placed  in  for  a  surgical  examination 
or  operation.  By  the  side  of  the  body  should  be  placed 
an  entire  articulated  skeleton.  Careful  notice  is  to  be 
taken  of  all  the  surface-markings,  and  of  the  superficial 
bearings  of  all  prominent  underlying  structures,  such  as 
the  subcutaneous  surfaces  of  the  bones,  ligaments,  ten- 
dons, and  bursse ;  the  proper  swellings,  or  contouring,  of 
the  muscles,  both  at  rest  and  in  action ;  the  course  of 
the  superficial  and  deep  vessels;  the  change  of  aspect  in 
regions,  dependent  upon  alteration  of  position ;  the  course 
and  direction  of  the  several  natural  passages  of  the  body ; 
the  anatomical  relations  of  the  lines  of  incision  required 
in  the  various  operations  of  surgery ;  and  the  altered 


Xll  INTRODUCTION. 

positions  of  bones  when  dislocated  compared  with  the 
normal  ones. 

In  studying  Regional  Anatomy  the  parts  must  be 
regarded  as  being  wounded,  either  by  the  surgeon's 
knife  or  by  some  weapon,  or  displaced  by  accident.  In 
the  various  stages  of  a  dissection  made  in  the  prosecution 
of  Descriptive  Anatomy,  it  is  often  the  end  and  aim  of 
the  dissector  to  make  a  clean  or  "  pretty  "  preparation, 
in  following  out  the  different  vessels,  nerves,  &c.,  and 
for  this  purpose  it  is  quite  right  that  all  pains  be  taken, 
but  the  student  must  remember  that  the  more  he  cleans, 
the  more  he  destroys  the  actual  relation  of  the  parts  as 
they  would  be  met  with  in  an  operation  ;  and,  moreover, 
he  must  remember  that  the  very  fasciae  he  so  studiously 
removes,  are  of  the  greatest  importance  in  Surgical 
Anatomy,  and  their  removal  destroys  surgical  conti- 
nuity. 

The  want  of  material  in  our  schools  is  the  great 
drawback  to  the  study  of  Topographical  Anatomy,  as 
bodies  cannot  be  spared  for  such  sections  and  special 
examinations  as  a  consideration  of  the  various  operative 
proceedings  of  surgery  suggests. 


in 


415 

f- 


THE  STUDENT'S  GUIDE 


TO 


SURGICAL  ANATOMY, 


CHAPTER  I. 
SURGICAL  ANATOMY  OF  THE  CRANIAL  REGION. 

Regions. — The  regions  into  which  the  cranium  is  di- 
vided for  the  sake  of  surgical  reference,  differ  in  number 
and  extent  in  the  various  works  upon  the  subject ;  thus 
some  make  four — viz.,  the  occipito-frontal,  the  temporal, 
the  auricular,  and  the  mastoid ;  but  for  simplicity  and 
more  ready  reference  the  following  would  seem  to  suffice, 
viz.,  the  occipito-frontal  and  the  temporo-parietal.  The 
external  investment  of  the  cranium  or  scalp  varies  in 
structure  in  these  several  regions,  and  will  be  considered 
in  the  dissection  of  each. 

The  occipito-frontal  region  is  oblong  in  shape.  Its 
limits  are — anteriorly,  the  anterior  margins  of  the  roofs 
of  the  orbits,  and  the  articulations  of  the  frontal  with 
the  superior  maxillary  and  nasal  bones ;  posteriorly,  by 
the  superior  curved  line  of  the  occipital  bone,  and  on 
each  side  by  the  temporal  ridge. 

Dissection. — An  incision  is  to  be  made,  commencing 

2 


14  SURGICAL    ANATOMY    OF 

in  front  at  the  root  of  the  nose,  and  is  to  be  carried  back- 
wards to  the  occipital  tuberosity  ;  a  second  at  right  angles 
to  it  across  the  scalp  from  ear  to  ear.  Care  must  be  taken 
that  the  depth  of  the  first  incisions  extends  no  farther 
than  the  hair-bulbs.  The  flaps  so  formed  are  next  to  be 
very  carefully  reflected  forwards  and  backwards. 

The  integument  is  tolerably  thick,  smooth,  and  some- 
what uneven  in  surface.  It  is  very  rich  in  sebaceous  fol- 
licles, and  these,  by  the  inspissation  of  their  contents  and 
closure  of  their  excretory  ducts,  constitute  the  encysted 
tumors  or  wens  so  often  met  with  in  this  region.  It  is 
highly  vascular,  and  is  frequently  the  seat  of  aneurisms 
by  anastomosis,  erectile  tumors,  &c.,  and  has  immediately 
subjacent  a  dense  lamellated  cellular  tissue,  containing  a 
little  nodulated  fat  and  the  hair-bulbs,  adhering  firmly 
to  the  underlying  tendinous  expansion  of  the  occipito- 
frontalis  muscle  or  epicranial  aponeurosis.  This  apon- 
eurosis  is  extremely  thin  over  the  vertex  of  the  cranium, 
but  very  thick  in  the  temporal  region,  and  freely  mova- 
ble. Effusions  of  blood  may  take  place  either  above  or 
below  this  structure  in  the  loose  areolar  tissue  separating 
it  from  the  pericranium.  Thus  a  "  black  eye  "  can  be 
produced  by  a  blow  on  the  back  of  the  head,  by  the 
gravitation  of  the  blood  downwards  and  forwards  into 
the  loose  subcutaneous  tissue  of  the  forehead  and  eyelids. 
In  phlegmonous  erysipelas  of  the  scalp  the  pus  burrows 
under  this  aponeurosis,  so  that  free  incisions  down  to  the 
bone  and  counter-openings  are  necessary.  Beneath  this 
cellular  layer  is  the  pericranium  or  external  periosteum, 
which  is  much  stronger  in  the  child  than  in  the  adult; 
it  is  frequently  the  seat  of  periostitis  and  of  nodes. 

The  arteries  supplying  this  region  are — in  front,  the 
supra-orbital,  the  frontal,  and  the  superficial  temporal, 


THE    CRANIAL    REGION.  15 

thus  forming  a  free  inosculation  between  the  internal  and 
external  carotid  arteries.  Behind,  the  occipital  and  the 
posterior  auricular  branches  of  the  external  carotid  artery 
freely  anastomose  with  each  other,  and  with  the  above- 
mentioned  vessels. 

The  superficial  temporal  artery,  which  is  easily  seen 
beneath  the  skin  in  its  tortuous  course,  is  liable  to  injury, 
which,  in  the  event  of  the  main  trunk  being  divided, 
either  entirely  or  partially,  may  be  serious  by  the  forma- 
tion of  a  false  aneurism  from  the  escape  of  blood  beneath 
the  tissues.  In  such  a  case  the  tumor  must  be  opened 
and  the  clot  turned  out,  and  both  ends  of  the  bleeding 
vessel  tied.  If  the  operation  of  arteriotomy  be" required, 
the  anterior  branch  of  this  vessel  is  the  one  selected,  just 
at  the  spot  where  it  begins  to  be  covered  by  the  hairy 
scalp.  In  performing  this  operation  a  small  puncture 
only  is  necessary,  and  when  complete  the  vessel  should 
be  entirely  divided,  so  that  by  the  retraction  of  the  cut 
ends  the  formation  of  a  false  aneurism  may  be  prevented. 
In  such  plastic  operations  as  the  restoration  of  the  upper 
eyelid,  or  of  rhinoplasty,  the  preservation  of  the  supra- 
orbital  arteries  is  of  great  importance  for  the  proper 
nourishment  of  the  flap. 

Veins. — The  arteries  are  generally  accompanied  by 
small  veins ;  one  vessel  in  particular,  the  vena  prceparata, 
which  is  situated  in  the  middle  of  the  forehead,  and  is 
plainly  visible  during  bodily  exertion  or  under  excite- 
ment, is  worthy  of  note.  This  vein  has  been  proposed 
as  suitable  for  venesection. 

The  nerves  supplying  the  muscles  and  integument,  are 
in  front,  the  supra-orbital  and  supra-trochlear  branches 
of  the  frontal,  and  some  few  inosculating  branches  of  the 
facial.  These  nerves  are  frequently  the  seat  of  neuralgia, 


16  SURGICAL    ANATOMY    OF 

and  for  its  relief  division  of  the  frontal  nerve  has  been 
proposed  at  its  point  of  exit  from  the  supra-orbital  notch. 

In  infancy  this  region  is  frequently  the  seat  of  ceph- 
alhsematomata  or  blood  tumors,  occurring  either  from 
compression  of  the  cranium  during  parturition,  or  from 
a  collection  of  blood  beneath  the  pericranium,  which  is 
very  loosely  attached  to  the  bone  at  this  period. 

Structures  divided  in  cutting  down  upon  the  Bone  in 
the  Occipito-frontal  Region. — Skin,  subcutaneous  cellular 
tissue,  occipito-frontalis  muscle,  and  epicranial  aponeu- 
rosis,  a  thin  layer  of  lax  cellular  tissue,  and  the  pericra- 
nium;  anteriorly  the  vessels  divided  are  the  temporal, 
the  frontal,  and  the  supra-orbital,  with  the  supra-orbital, 
supra-trochlear,  and  branches  of  the  auriculo-temporal 
nerves,  and  posteriorly  the  occipital  vessels  and  greater 
and  lesser  occipital  nerves. 

The  Temporo-parietal  Region. — The  superior  limit  of 
this  region  is  the  lateral  boundary  of  the  occipito-frontal, 
and  its  inferior  limit  is  a  line  drawn  from  the  external 
angle  of  the  frontal  bone  to  the  mastoid  process  of  the 
temporal. 

Dissection. — The  integument  and  subcutaneous  cellular 
tissue  are  pretty  much  the  same  as  in  the  preceding  re- 
gion. The  structures  met  with  on  reflecting  the  integu- 
ment are — a  superficial  aponeurosis,  very  tough,  upon 
which  is  the  temporal  artery  ;  a  second  aponeurosis  lined 
with  fat  and  cellular  tissue,  and  the  small  auricular 
muscles.  The  temporal  fascia  is  attached  above  to  the 
curved  line  limiting  the  temporal  fossa,  and  to  the 
zygoma  below;  by  its  under  surface  it  gives  attachment 
to  the  temporal  muscle,  in  which  lie  the  deep  temporal 
arteries  from  the  internal  maxillary,  with  their  accom- 
panying veins.  The  deep  temporal  arteries  freely  inos- 


THE    CRANIUM.  17 

culate  with  the  superficial  and  with  the  occipital  and 
posterior  auricular  which  supply  the  hinder  part  of  this 
regipn.  The  arrangement  of  the  several  aponeuroses  in 
this  region  determines  the  course  taken  by  purulent  col- 
lections ;  thus,  supposing  the  matter  to  be  deepseated,  it 
will  make  its  way  into  the  zygomatic  fossa,  and  when 
superficial  it  will  be  limited  by  the  tough  aponeurosis 
already  mentioned.  The  posterior  part  of  this  region, 
which  contains  the  mastoid  process  of  the  temporal  bone, 
is  the  seat  of  an  operation  proposed  for  the  opening  of 
the  mastoid  cells  with  the  object  of  giving  vent  to  matter 
pent  up  in  them,  should  it  not  find  its  way  either  by  the 
Eustachian  tube  or  through  the  external  auditory  meatus. 
Fractures  in  this  region  are  frequently  complicated  with 
laceration  of  the  middle  rneningeal  artery,  which  runs 
over  the  internal  aspect  of  the  cranium. 

This  region  contains  numerous  lymphatic  ganglia, 
which  become  remarkably  indurated  in  constitutional 
syphilis. 

The  structures  divided  in  cutting  down  upon  the  bone  in 
the  temporo-parietal  region  are — the  skin,  subcutaneous 
fascia,  epicranial  aponeurosis,  superficial  temporal  apon- 
eurosis, deep  temporal  aponeurosis,  temporalis  muscle 
and  tendon,  with  the  superficial  and  deep  temporal  ves- 
sels, nerves,  and  lymphatics. 

SURGICAL  ANATOMY  OF  THE  CKANIUM. 

The  structure  of  the  cranial  bones  forming  the  vault 
of  the  skull  consists  of  three  layers ;  an  outer,  formed  of 
tough  compact  tissue;  an  intermediate,  the  diploe,  soft 
and  spongy,  having  the  diploic  veins  ramifying  in  its 
substance ;  and  an  inner,  hard  and  brittle.  These  di- 
ploic veins,  after  injury  followed  by  suppuration,  are  lia- 


18         SURGICAL    ANATOMY    OF    THE    CRANIUM. 

ble  to  inflammation  ;  which  circumstance  explains  the 
formation  of  secondary  deposits  of  pus  in  various  parts 
of  the  body,  most  frequently  in  the  lungs  and  liver.  The 
brittleness  of  the  internal  layer  is  of  surgical  importance 
from  the  fact  that,  in  blows  on  the  head,  it  is  more  lia- 
ble to  be  fractured  than  the  outer ;  and  cases  have  oc- 
curred where  it  has  been  broken  without  any  apparent 
depression  whatever  of  the  external,  giving  rise  to  symp- 
toms of  compression  which  would  otherwise  have  been 
difficult  of  explanation.  The  diploe  is  not  easily  dis- 
tinguished in  young  persons.  In  the  application  of  the 
trephine,  the  varying  densities  of  the  layers  of  the  skull 
must  be  borne  in  mind,  as  the  pressure  upon  the  instru- 
ment on  its  first  application  must  be  firm  and  steady, 
until  the  external  table  is  perforated,  when  there  is  less 
resistance.  When  it  is  quite  perforated  the  blood  of  the 
diploe  will  be  seen  in  its  teeth.  The  pin  of  the  trephine 
is  now  to  be  withdrawn,  to  avoid  its  being  pushed 
through  the  inner  table  into  the  dura  mater  and  en- 
cephalon  ;  the  inner  table,  though  thinner,  will  be  found 
to  offer  more  resistance  to  the  saw  edge.  There  are  cer- 
tain localities  in  the  skull  where  the  application  of  the 
trephine  should  be  avoided.  These  are — over  the  lon- 
gitudinal sinus,  the  anterior  inferior  angle  of  the  parietal 
bone,  because  of  the  middle  meningeal  artery,  over  the 
occipital  tuberosity,  and  over  the  sutures. 

The  arrangement  of  the  various  sutures  of  the  bones 
forming  the  vault  of  the  cranium  has  greater  interest 
for  the  obstetrician  than  the  surgeon,  as  any  peculiari- 
ties connected  therewith  exist  normally  only  in  foetal 
life  or  early  childhood.  The  bones  of  the  skull  in  the 
fetus  or  newly-born  child  are  flexible,  and  between  their 
undeveloped  sutures  are  the  fontanettes,  the  position  of 


SURGICAL  ANATOMY  OF  THE  CRANIUM. 


19 


which  is  of  importance.  The  sagittal  suture,  extending 
from  the  root  of  the  nose  to  the  occiput,  is  crossed  at 
right  angles  by  the  coronal ;  at  the  point  of  intersection 
of  these  sutures  is  the  anterior  and  larger  fontanelle. 
At  the  point  where  the  lambdoidal  suture  crosses  the 
sagittal  is  the  posterior  fontanelle,  generally  closed  at 
birth,  and  recognizable  by  the  peculiar  convergence  of 
the  three  sutures.  Hernia  cerebri  is  the  result  of  in- 
complete closure  of  these  spaces,  which,  however,  are 
generally  ossified  by  the  fourth  year. 


FIG.  1. 


Diagram  of  structures  to  be  avoided  in  use  of  trephine.    1,  2,  3.  Branches  of 
middle  meningeal  artery.    4.  Lateral  sinus.    5.  Superior  longitudinal  sinus. 


Fracture  of  the  base  of  the  skull  by  "  contre-coup  "  is 
denied  by  some,  on  the  ground  that  the  shock  is  resisted 
by  the  cranium,  and  that  the  results  of  such  shocks,  as 
in  the  case  of  architectural  arches,  are  lost  upon  its  sup- 
porting pillars,  which,  in  the  frontal  region,  are  the 
malar  and  sphenoid  bones,  in  the  parietal  the  temporal 


20    SURGICAL  ANATOMY  OF  THE  CRANIUM. 

bones,  and  in  the  occipital  region  the  ribs  of  the  occipi- 
tal bone  itself. 

In  almost  all  cases,  when  the  cranium  is  struck,  the 
parietal  region  is  the  seat  of  the  injury  ;  the  bone  is 
fractured  at  the  spot,  and  the  line  of  fracture  runs 
through  the  temporal  bone,  which,  from  the  fact  of  its 
containing  so  many  cavities  and  foramina,  its  texture, 
and  the  inclination  of  the  axis  of  the  petrous  portion, 
readily  gives  way.  A  fracture  of  the  base  may  also 
occur  from  a  fall  on  the  feet  or  on  the  buttock,  the  force 
being  transmitted  along  the  spinal  column,  and  meeting 
the  skull  at  the  condyles.  Rupture  of  the  brain-sub- 
stance, however,  is  common  by  contre-coup.  The  course 
of  such  fractures  of  the  base  may  be  anatomically  deter- 
mined by  the  effects  produced  upon  the  nerves  issuing 
from  the  skull,  the  most  frequent  being  facial  paralysis 
from  lesion  of  the  portio  dura  whilst  in  the  aqueductus 
Fallopii. 

Fractures  of  the  base  of  the  cranium  are  generally 
associated  with  ecchymosis  of  the  eyelids  and  effusion 
of  blood  from  the  external  auditory  meatus.  The  exist- 
ence of  subconjunctival  ecchymosis  is  of  great  impor- 
tance in  the  diagnosis  of  this  injury ;  the  escaped  blood 
infiltrates  the  cellular  tissue  of  the  orbit,  passes  through 
the  openings  in  the  capsule  of  Tenon,  and  so  gets  into 
the  subconjunctival  cellular  tissue  (vide  Orbital  Region). 

The  surgical  anatomy  of  the  temporal  bone  presents 
considerable  additional  points  of  practical  importance, 
as  it  contains  the  organ  of  hearing  and  the  parts  acces- 
sory to  it. 

The  external  auditory  canal  has  a  direction  inwards 
and  forwards,  describing  a  slight  general  curve,  the  con- 
cavity of  which  is  downwards.  The  outer  third  of  the 


SURGICAL    ANATOMY    OF    THE    CRANIUM.          21 

passage  is  formed  by  a  tubular  prolongation  inwards  of 
the  cartilage  of  the  external  ear,  which,  however,  is  not 
complete  at  the  upper  part;  and  its  inner  two-thirds  by 
the  canal  in  the  temporal  bone.  There  are  several  small 
fissures  in  the  cartilaginous  part,  which  are  sometimes 
very  wide  apart — a  circumstance  explaining  the  passage 
of  pus  into  the  meatus,  from  abscesses  which  have  formed 
external  to  it.  In  length  the  meatus  is  about  an  inch 
and  two  or  three  lines ;  but  owing  to  the  obliquity  of  the 
attachment  of  the  membrana  tympani,  its  anterior  wall 
is  about  one-quarter  of  an  inch  longer  than  the  posterior. 
Its  narrowest  diameter  is  about  the  middle,  and  in 
making  an  examination  with  the  speculum  auris  the  in- 
strument should  not  be  introduced  further  than  this  point. 
It  must  be  borne  in  mind  that  in  young  children  the 
meatus  is  very  shallow,  the  bony  part  consisting  only  of 
a  small  ring  of  bone,  deficient  at  the  upper  part,  to  which 
the  membrana  is  attached. 

To  facilitate  the  introduction  of  the  speculum,  the  au- 
ricle should  be  drawn  upwards,  backwards,  and  a  little 
outwards ;  this  renders  the  canal  tolerably  straight. 

The  membrana  tympani  is,  on  examination,  grayish  in 
color,  its  fibrous  structure  looking  radiated,  slightly  con- 
ical, with  the  apex  directed  inwards,  and  placed  very 
obliquely  at  the  bottom  of  the  meatus.  The  handle  of 
the  malleus  is  seen  through  the  membrane,  not  quite 
vertical,  but  inclining  a  little  backwards.  The  points  of 
practical  importance  connected  with  the  tympanum  are 
these — that  its  upper  aspect  and  floor  are  formed  by  thin 
lamellae  of  bone  separating  it  from  the  cranium  and  from 
the  canal  for  the  internal  carotid  artery,  so  that  disease 
of  the  bone  causes  death,  either  by  involving  the  dura 
mater  and  brain,  or  from  ulceration  into  the  vessel.  The 


22      SURGICAL  ANATOMY  OF  THE  FACE. 

close  vicinity  of  the  carotid  artery  and  lateral  sinus 
readily,  accounts  for  the  escape  of  blood  from  the  ear  in 
fracture  of  the  base  of  the  cranium. 

The  JEustachian  tube  is  the  means  of  communication 
between  the  internal  ear  and  the  pharynx,  and  serves 
to  maintain  the  balance  of  air  on  either  side  of  the  mem- 
bran  a  tympani. 

Its  internal  orifice  is  at  the  anterior  internal  aspect  of 
the  tympanum.  The  tube  is  directed  downwards  and 
forwards,  and  terminates  in  a  flattened  valve-like  open- 
ing in  the  pharynx,  just  behind  and  a  little  above  and 
external  to  the  inferior  meatus  of  the  nose.  Its  mucous 
membrane  is  continuous  with  that  of  the  pharynx.  The 
pharyngeal  extremity  of  the  tube  is  in  close  relation  with 
the  tonsil — a  fact  which  explains  its  temporary  occlu- 
sion in  enlargement  or  inflammation  of  that  gland. 

(The  operation  of  introducing  the  Eustachian  catheter 
is  explained  at  p.  31.) 

SURGICAL  ANATOMY  OF  THE  FACE. 

Dissection. — Before  commencing  a  dissection  to  dis- 
play the  various  structures  met  with  in  the  integument 
of  the  face,  a  little  tow  should  be  inserted  into  the  eye- 
lids, buccal  cavity,  and  nostrils,  to  make  tense  these 
regions.  An  incision  is  then  to  be  made  from  above  the 
zygoma  to  the  angle  of  the  jaw,  and  another  meeting  it 
along  the  base  of  the  jaw  to  the  middle  of  the  chin.  The 
skin-flap  is  then  to  be  raised  from  behind  forwards,  and 
left  adherent  along  the  middle  line.  Great  care  must 
be  taken  in  so  doing,  as  the  facial  muscles,  or  "  muscles 
of  expression/7  are  inserted  into  the  skin,  and  are  easily 
removed  in  dissection. 


SURGICAL    ANATOMY    OF    THE    FACE.  23 

The  skin  of  the  face  is  remarkably  thin,  freely  sup- 
plied with  vessels,  nerves,  and  follicles.  The  subcuta- 
neous cellular  tissue  is  dense,  and  contains  (except  on 
the  eyelids)  a  good  deal  of  fat.  A  description  of  the  at- 
tachments, relations,  and  uses  of  the  muscles  of  the  face 
win  be  found  in  works  on  general  or  artistic  anatomy. 

Arteries. — The  chief  arterial  supply  of  the  face  is  de- 
rived from  the  external  carotid,  its  facial,  internal  max- 
illary, and  transverse  facial  branches,  and  from  the 
ophthalmic  branches  of  the  internal  carotid.  Their 
inosculation  is  remarkably  free.  The  normal  course  of 
the  facial  artery,  when  it  appears  on  the  face,  is  just  an- 
terior to  the  masseter  muscle,  where  it  is  subcutaneous, 
and  here  only  is  it  in  actual  relation  with  the  accom- 
panying facial  vein,  which  is  almost  straight,  and  lies  to 
its  outer  side.  The  vessel  ascends  from  this  point  tor- 
tuously, more  particularly  so  in  old  persons,  towards  the 
corner  of  the  mouth,  side  of  the  nose,  and  inner  angle  of 
orbit,  where  it  inosculates  with  the  ophthalmic.  The 
artery  lies  at  first  under  the  platysma,  and  further  on  in 
its  course  is  covered  by  some  thin  fibres  of  the  zygomat- 
icus  major.  The  chief  named  branches  are  the  inferior 
labial,  running  between  the  lower  lip  and  the  chin,  and 
distributed  to  its  integument ;  the  coronary,  superior 
and  inferior,  distributed  to  each  lip  and  to  the  septum  of 
the  nose;  the  lateral  nasal,  to  the  side  of  the  nose;  and 
the  angular,  a  large  branch  going  to  the  inner  angle  of 
the  orbit,  generally  seen  pulsationg  under  the  skin.  The 
transverse  facial  artery  is  a  branch  generally  of  the  tem- 
poral, lying  by  the  side  of  the  duct  of  the  parotid  gland 
(Steno's),  accompanied  by  branches  of  the  facial  nerve. 
Those  branches  which  the  internal  carotid  supplies  to 
the  face  are  the  terminal  ones  of  the  ophthalmic — namely, 


24  SURGICAL    ANATOMY    OF    THE    FACE. 

the  supra-orbital  and  supra-trochlear,  which  escape  by 
the  supra-orbital  and  supra-trochlear  notches.  Large 
inosculating  vessels  escape  through  several  foramina  in 
the  bones  of  the  face,  from  deep  branches  of  the  external 
carotid — viz.,  the  infra-orbital,  passing  out  of  the  infra- 
orbital  foramen ;  from  the  mental  foramen,  and  a  large 
branch  from  the  same  source  is  found  on  the  substance 
of  the  buccinator.  The  free  inosculation  of  the  arteries 
of  the  face  renders  ligature  of  both  ends  of  a  divided 
facial  artery  necessary,  as  the  return  circulation  is  very 
quickly  re-established ;  and,  in  wounds,  whether  the  re- 
sults of  accident  or  surgical  interference,  very  accurate 
approximation  of  the  edges  must  be  obtained,  for  union 
takes  place  very  rapidly,  and  distortion  is  not  so  easily 
remedied.  The  bloodvessels  of  the  face  are  frequently 
subject  to  a  na3void  condition. 

The  nerves  of  the  face  are  derived  from  the  three  di- 
visions of  the  5th,  and  from  the  portio  dura  or  facial 
part  of  the  7th  cerebral  nerve.  The  branches  from  the 
1st  division  of  the  5th  are — the  supra-orbital,  supra- 
trochlear,  infra-trochlear,  lachrymal,  and  nasal.  From 
the  2d — the  infra-orbital,  passing  out  of  the  infra-orbital 
foramen,  and  the  subcutaneous  malse.  The  buccal  from 
the  same  source  emerges  just  in  front  of  the  anterior 
border  of  the  masseter.  From  the  3d  division — the 
masseteric,  and  the  inferior  dental  from  the  foramen 
mentale.  The  facial  forms  a  plexus  in  the  parotid  gland, 
after  which  it  passes  into  a  great  many  branches,  and  is 
supplied  to  the  muscles  of  the  face,  having  free  inoscula- 
tions with  the  branches  of  the  5th  nerve.  The  infra- 
orbital  nerve  is  peculiarly  liable  to  neuralgic  affections. 
Twitchings  of  the  muscles  of  the  face  are  connected  with 


SURGICAL    ANATOMY    OF    THE    FACE.  25 

affections  of  the  facial.  Both  nerves  are  occasionally 
palsied. 

The  lymphatic  ganglia  of  the  face  are  most  thickly 
situated  along  the  base  of  the  jaw,  on  it  and  the  bucci- 
nator muscle,  others  under  the  zygoma,  and  beneath,  in, 
or  upon  the  parotid  gland.  The  ganglia  around  the 
mouth  are  sometimes  affected  with  syphilitic  induration 
after  the  application  of  the  specific  virus  to  the  lips.  The 
cellular  tissue  being  very  lax,  and  loosely  attached  to 
the  subjacent  structures,  it  is  very  liable  to  the  infil- 
tration of  fluids,  or  of  air,  as  in  wounds  of  the  frontal 
sinuses  or  larynx.  As  the  fasciaB  of  the  face  are  very 
thin  and  ill-defined,  abscesses  in  this  region  point  early. 

The  congenital  malformations  consist  of  closure  of  its 
apertures,  arrests  of  development,  such  as  single  and 
double  hare-lip,  frequently  associated  with  cleft-palate. 
The  aperture  of  the  nostrils  is  occasionally  single. 

The  facial  relations  of  the  parotid  gland  (anterior  por- 
tion and  socia-parotidis)  are  of  importance  so  far  as  they 
are  concerned  in  the  removal  of  growths,  and  in  opera- 
tions for  salivary  fistulse.  The  gland  is  situated  just  in 
front  of  and  below  the  ear,  the  deeper  portion  lying  be- 
hind the  angle  of  the  jaw,  limited  above  by  the  zygoma 
(vide  Parotid  Region).  On  the  face  it  overlaps  the  mas- 
seter  to  a  variable  extent,  having  generally  a  small  ac- 
cessory portion  just  in  front  of  it,  called  the  socia-paro- 
tidis. Its  duct  runs  forward  to  the  anterior  edge  of  the 
masseter,  and  dips  inward  to  open  obliquely  through  the 
cheek,  opposite  the  second  molar  tooth  of  the  upper  jaw. 
Its  course  is  defined  by  a  line  extending  from  the  upper 
border  of  the  lobe  of  the  ear  to  midway  between  the 
nostril  and  the  angle  of  the  mouth ;  and  great  care  must 
be  taken  in  operations  on  the  face  to  avoid  its  division, 


26  SURGICAL    ANATOMY    OF    THE    NOSE. 

as  salivary  fistula  would  be  the  result.  The  various 
structures  which  constitute  the  entire  face  will  be  found 
described  in  their  surgical  relations,  with  the  deeper  re- 
gions beneath  them. 

SUEGICAL  ANATOMY  OF  THE  REGION  OF  THE 
NOSE. 

The  structure  of  the  skin  of  the  nose  is  very  similar  to 
that  in  other  parts  of  the  body,  except  that  it  is  very 
thin  and  loosely  connected  with  the  subjacent  parts.  The 
hairs  are  but  rudimentary,  and  the  sebaceous  glands  very 
numerous  and  largely  developed.  These  orifices  show 
themselves  as  points  more  or  less  deep,  most  abundant 
on  the  alse.  Underneath  is  a  layer  of  cellular  tissue  very 
adherent  to  the  skin  and  subjacent  musculo-fi brous  tissues 
containing  a  little  fat. 

The  muscles  of  the  nose  belong  to  those  of  expression, 
and  are  as  follows :  pyramidalis  nasi,  levator  labii  stiper- 
ioris  et  alse  nasi,  dilator  naris,  compressor  nasi,  compressor 
narium  minor,  depressor  alse  nasi. 

The  arteries  of  the  nose  are  derived  from  the  ophthal- 
mic and  the  facial,  the  sides  and  dorsum  being  supplied 
by  the  nasal  branch  of  the  ophthalmic  and  the  infra- 
orbital,  the  alse  and  septum  by  the  superior  coronary, 
and  by  the  lateralis  nasi. 

The  veins  terminate  in  the  facial  and  ophthalmic. 

The  nerves  are  derived  from  the  facial,  infra-orbital, 
infra-trochlear,  and  a  twig  from  the  nasal  branch  of  the 
ophthalmic  of  the  fifth. 

There  are  numerous  lymphatics,  which  empty  them- 
selves into  the  submaxillary  glands  (lymphatic),  and  fol 
low  the  course  of  the  facial  vein. 


SURGICAL    ANATOMY    OF    THE    NOSE.  27 

The  mucous  membrane  lining  the  nostrils  is  continu- 
ous with  the  skin  and  that  of  the  nasal  fossse. 

The  nasal  cartilages,  forming  the  softer  portion  of  its 
framework,  are  five  in  number — viz.,  two  upper  lateral, 
and  two  lower  lateral  and  the  cartilage  of  the  septum. 

Each  upper  lateral  cartilage  is  flattened  and  triangular 
in  shape.  Its  anterior  margin  articulates  with  the  car- 
tilage of  the  septum.  The  posterior  edge  articulates  with 
the  nasal  process  of  the  superior  maxillary  and  nasal 
bones.  The  lower  edge  is  connected  by  fibrous  tissue 
with  the  lower  lateral  cartilage. 

The  alar  or  lower  lateral  cartilages  are  two  in  number, 
and  completely  separate.  They  are  of  the  form  of  a 
horseshoe,  with  the  concavity  posterior,  and  with  the 
external  limb  longer  than  the  internal.  The  convexity 
of  these  two  cartilages  is  situated  in  the  thickness  of  the 
lobe,  on  each  side  of  the  anterior  inferior  angle  of  the 
cartilage  of  the  septum.  The  inner  limb  of  this  carti- 
lage has  its  back  against  that  of  the  opposite  side  and  to 
the  cartilage  of  the  septum  in  the  median  line. 

There  are  three  or  four  small  cartilaginous  plates, 
situated  in  the  tough  membrane  connecting  the  lower 
lateral  (alar)  cartilage  with  the  nasal  process  of  the 
superior  maxilla — the  sesamoid. 

The  alse  of  each  side  are  further  composed  of  masses 
of  cellular  tissue  placed  below  and  behind  the  alar  car- 
tilages. 

The  bony  framework  is  formed  by  the  nasal  bones,  to 
which  the  external  nose  owes  its  form  in  a  great  measure ; 
their  method  of  articulation  with  the  frontal  and  superior 
maxillary  greatly  determining  its  shape  and  dimensions. 

These  two  oblong  bones  form  by  their  junction  along 
the  middle  line  in  front  the  "  bridge  "  of  the  nose ;  they 


28         SURGICAL  ANATOMY  OF  THE 

articulate  with  the  frontal  and  ethmoid,  with  the  superior 
maxilla  and  with  each  other.  The  alar  cartilages  articu- 
late by  their  lower  edges. 

The  great  vascularity  of  the  nose  and  of  the  adjacent 
parts  renders  union  after  wounds  very  rapid ;  indeed, 
there  are  cases  where  the  entire  organ  has  been  cut  off, 
and  been  for  some  little  while  removed  from  the  body, 
reuniting  entirely  after  careful  adjustment.  Plastic 
operations  for  the  restoration  of  the  nose  depend  greatly 
for  their  success  on  the  surgeon's  ingenuity  but  also  on 
so  fashioning  the  flaps  that  they  retain  the  vessels  in  their 
continuity,  thus  providing  for  their  thorough  nourish- 
ment. 

SUKGICAL  ANATOMY  OF  THE  NASAL  FOSSAE  AND 
SINUSES  OF  THE  NOSE. 

Before  exposing  the  contents  of  the  nasal  fossae,  an 
opportunity  should  be  taken  of  examining  the  nares  by 
means  of  the  speculum,  of  performing  the  operation  of 
passing  probes  into  the  nasal  ducts  and  Eustachian  tubes, 
of  plugging  the  posterior  nares,  of  introducing  the  fingers 
and  instruments  for  the  detection  or  removal  of  nasal  and 
pharyngeal  polypi,  &c. 

Dissection. — The  saw  is  to  be  entered  on  one  or  other 
side  of  the  crista  galli,  and  to  be  carried  gently  down- 
wards through  the  frontal  and  nasal  bones,  the  cribri- 
form plate,  and  a  portion  of  the  body  of  the  sphenoid ; 
the  hard  palate  on  the  same  side  is  next  to  be  sawn 
through,  the  soft  parts  cut  through  with  a  scalpel  in  the 
same  line,  and  the  remaining  portion  of  the  body  of  the 
sphenoid  divided.  The  nasal  cavity  being  thus  divided, 
one-half  will  show  the  septum  and  the  other  the  mea- 
tuses.  Each  nasal  fossa  presents  for  examination  a  roof, 


NASAL    FOSSJ3    AND    SINUSES    OF    THE    NOSE.      29 

floor,  internal  wall,  external  wall,  and  the  anterior  and 
posterior  nares.  The  vertical  diameter  of  the  nasal  fossae 
is  greater  at  the  middle  of  the  cavities  than  at  the  an- 
terior or  posterior  parts,  and  the  transverse  diameter 
greater  below  than  above. 

The  roof  is  formed  by  the  nasal  bones,  the  nasal  spine 
of  the  frontal,  the  cribriform  plate  of  the  ethmoid,  and 
the  body  of  the  sphenoid.  It  is  to  be  noted  that  the 
entire  roof  is  not  horizontal,  the  cribriform  plate  only 
being  so,  and  that  it  slopes  downwards  at  front  and 
back. 

The  floor  is  formed  by  the  palate  plates  of  the  superior 
maxillary  and  palate  bones. 

The  internal  wall  or  septum  is  formed  chiefly  by  the 
perpendicular  plate  of  the  ethmoid  and  by  the  vomer ; 
the  septal  plane  is  further  assisted  by  the  nasal  spine 
of  the  frontal,  the  crests  of  the  nasal,  superior  maxilla, 
and  palate  bones.  (The  septum  is  rendered  complete  by 
the  triangular  cartilage,  which  projects  forwards,  assist- 
ing in  giving  shape  and  prominence  to  the  nose.) 

The  outer  wall  is  divided  into  the  three  meatuses  by 
the  projection  from  it  of  the  three  turbinated  bones.  It 
is  formed  by  the  nasal,  the  superior  maxillary,  the  lat- 
eral mass  of  the  ethmoid,  and  the  lachrymal  bones ;  pos- 
teriorly by  the  ascending  plate  of  the  palate,  and  the  in- 
ternal pterygoid  plate  of  the  sphenoid ;  the  wall  is  com- 
pleted by  the  lateral  cartilages. 

Meatuses. — The  outer  wall  of  each  fossa  is  subdivided 
into  three  (sometimes  four)  irregular  channels,  termed 
rneatuses  —  viz.,  superior,  middle,  and  inferior.  The 
bones  entering  into  the  formation  of  these  meatuses  are 
all  those  of  the  face,  excepting  the  malar  and  inferior 
maxilla. 

3 


30 


SURGICAL    ANATOMY    OF    THE 


They  are  divided  by  the  three  turbinated  bones. 

The  superior  meatus  lies  beneath  the  superior  spongy 
bone,  and  is  the  smallest,  and  has  opening  into  it  the 
posterior,  ethmoidal,  and  sphenoidal  cells.  At  the  back 
is  the  spheno-palatine  foramen,  communicating  with  the 
spheno-maxillary  fossa. 


FIG.  2. 


a.  Position  of  nasal  duct.    b.  Orifice  of  Eustaohian  tube.    c.  Orifice  of  Steno's 
duct.    d.  Tonsil  between  pillars  of  fauces. 

The  middle  meatus  lies  beneath  the  middle  spongy 
bone,  and  has  opening  into  it  in  front,  the  frontal  sinus 
(inftmdibulum),  the  anterior  ethmoidal  cells,  and  the 
opening  of  the  antrum,  which  is  almost  impossible  to 
find  on  the  living  body.  (Vide  Superior  Maxillary 
Region.) 


NASAL    FOSS.E    AND    SINUSES    OF    THE    NOSE.      31 

The  inferior  meatus,  the  largest  and  most  important, 
lies  beneath  the  inferior  spongy  bone ;  it  extends  almost 
the  whole  length  of  the  fossa ;  its  lower  border,  thick 
and  rounded,  descends  almost  to  the  floor,  sometimes 
converting  the  meatus  into  a  canal ;  anteriorly,  where  it 
joins  the  nasal  process  of  the  superior  maxilla  is  the 
orifice  of  the  nasal  duct. 

The  opening  into  it  is  the  nasal  duet.  This  canal 
extends  from  the  orifice  in  the  meatus  to  the  lachrymal 
sac  (vide  Orbital  Region),  and  this  orifice  is  situated 
about  half  an  inch  behind  the  ascending  plate  of  the 
superior  maxilla,  and  nearly  opposite  the  centre  of  the 
under  surface  of  the  lower  turbinated  bone.  It  is  some- 
what valvular,  owing  to  the  folds  of  mucous  membrane 
which  pass  into  the  aperture  and  which  are  continued 
up  the  tube.  It  takes  a  direction  from  below,  outwards, 
forwards,  and  upwards. 

To  pass  a  probe  into  the  nasal  duct,  the  instrument 
should  be  first  bent  into  the  shape  of  an  italic  /,  which 
should  be  passed  first  along  the  floor  of  the  fossa,  with 
its  concavity  towards  the  entrance ;  the  point  is  next  to 
be  pushed  gently  beyond  the  ascending  plate  of  the 
superior  maxilla,  and  kept  in  close  contact  with  the 
outer  wall ;  then  it  is  to  be  slightly  rotated  between  the 
fingers,  until  the  point  presents  upwards  and  outwards 
towards  the  eye;  if  the  handle  be  now  depressed,  it 
should  enter  the  canal. 

The  orifice  of  the  Eustachian  tube  is  a  valvular  aper- 
ture, situated  on  the  inner  surface  of  the  internal  ptery- 
goid  plate,  and  just  above  the  posterior  extremity  of  the 
inferior  turbinated  bone.  To  introduce  a  sound  or  probe 
into  it  the  extremity  of  the  instrument  should  be  bent 
at  an  angle  of  about  60°,  and  passed  along  the  floor  of 


32         SURGICAL  ANATOMY  OF  THE 

the  nostril  with  the  concavity  downwards,  then  pushed 
backwards  by  the  side  of  the  septum  until  the  mucous 
membrane  of  the  back  of  the  pharynx  is  reached ;  next 
it  is  to  be  slightly  withdrawn,  and  rotated  between  the 
fingers,  so  as  to  bring  its  point  upwards  and  outwards, 
which  may  be  known  to  be  in  the  orifice  of  the  tube 
when  it  cannot  be  made  to  rotate  easily. 

The  mucous  membrane  lining  the  nares  completely 
covers  the  surfaces  of  the  above-mentioned  bony  parts, 
terminating  in  front  at  its  juncture  with  the  skin.  In 
color  it  is  red,  and  its  superior  surface  is  studded  with 
orifices  of  glands  which  secrete  mucus.  It  is  of  variable 
thickness,  and  is  very  thin  where  it  is  prolonged  into 
the  several  sinuses.  It  is  thickest  on  the  septum,  espe- 
cially so  at  its  anterior  half.  It  is  moderately  thick  on 
the  roof  of  the  fossa,  where  it  invests  the  proper  bones 
of  the  nose  and  the  cribriform  plate  of  the  ethmoid ;  it 
enters  the  sphenoidal  sinus,  and  becomes  very  thin.  It 
covers  the  anterior  ethmoidal  cells  and  the  superior 
spongy  bones ;  it  sinks  into  the  groove  separating  this 
bone  from  the  sphenoidal  sinus,  and  closes  the  spheno- 
palatine  canal ;  and  so  it  may  be  traced  over  each  por- 
tion of  the  bony  and  cartilaginous  structure  to  be  con- 
tinuous behind  with  the  pharyngeal  membrane  and  with 
the  skin  of  the  face  in  front. 

Arteries. — This  membrane  is  supplied  by  the  spheno- 
palatine  branch  of  the  internal  maxillary,  which  divides 
into  two  branches;  the  more  internal  being  distributed 
to  the  septum,  divides  and  passes  towards  the  anterior 
palatine  foramen ;  the  external  is  distributed  to  the 
external  parietes,  and  subdividing  supplies  the  meatuses 
and  spongy  bones. 


NASAL    FOSSAE    AND    SINUSES    OF    THE    NOSE.      33 

There  are  also  branches  from  the  superior  dental 
(internal  maxillary)  to  the  antrum,  from  the  infra-or- 
bital, from  the  pterygo-palatine,  and  from  the  ethmoidal 
(ophthalmic)  and  facial. 

Veins.  —  The  veins  form  a  peculiarly  complicated 
plexus  (rete  nasi),  which  collect  and  pass  forwards, 
terminating  in  the  facial  vein;  others  pass  into  the 
frontal  vein,  and  another  set  pass  through  the  spheno- 
palatine  foramen  into  the  plexus  in  the  zygomatic  fossa. 

Nerves. — There  are  two  sets  of  nerves  distributed  to 
the  mucous  membrane  of  the  nose,  viz.  («)  those  of 
special  sense ;  (/?)  those  of  common  sensation. 

(«)  The  olfactory,  derived  from  the  olfactory  lobe, 
penetrates  in  three  layers  the  cribriform  plate  of  the 
ethmoid  bone,  and  is  distributed  to  the  ethmoidal  and 
sphenoidal  spongy  bones,  and  to  the  upper  part  of  the 
septum,  (ft)  Those  derived  from  the  fifth  are  the  nasal 
from  the  ophthalmic  division,  which  passes  to  the  an- 
terior part  of  the  mucous  membrane,  and  leaves  the 
cavity  of  the  nose  by  passing  between  the  lateral  car- 
tilage and  the  nasal  bone  (entering  by  the  nasal  slit). 
From  MeckePs  ganglion  are  given  off  the  spheno-pal- 
atine  branch  for  the  septum  and  the  external  parietes ; 
the  posterior  and  inferior  nasal  from  the  anterior  pal- 
atine, which  is  distributed  to  the  posterior  inferior  por- 
tion of  the  external  wall. 

There  is  a  point  of  considerable  practical  importance 
with  regard  to  the  relation  borne  by  the  velum  pen- 
dulum palati  to  the  posterior  nasal  apertures.  If  the 
mouth  be  opened,  there  is  an  involuntary  disposition  to 
breathe  through  it,  and  thus  the  palate  applies  itself 
closely  to  the  walls  of  the  pharynx,  cutting  off  the  com- 
munication between  the  nose  and  mouth.  In  syring- 


34  SURGICAL    ANATOMY    OF 

ing  out  the  nostrils,  it  will  be  found  that  if  the  mouth 
be  open  and  the  nozzle  of  the  instrument  be  introduced 
into  one  of  the  anterior  openings,  the  current  of  fluid 
will  wash  out  the  entire  nasal  cavity,  and  pass  out 
through  the  other  again.  In  the  case  of  the  introduc- 
tion of  the  mirror  in  posterior  rhinoscopy,  the  palate 
must  be  forced  forward  by  the  emission  of  nasal  sounds, 
or  drawn  forwards  by  hooks  or  forceps  constructed  for 
the  purpose. 

Nasal  polypi  of  the  fibro-cellular  variety  developed 
in  the  submucous  tissue  of  this  region  are  covered  with 
ciliated  epithelium,  and  are  usually  attached  to  one  of 
the  superior  turbinated  bones.  The  more  formidable 
forms  of  growths  generally  project  into  the  fossae  from 
the  antrum  or  base  of  skull.  The  posterior  nares,  oval 
in  form  and  of  the  same  shape  as  their  bony  boundaries, 
enter  into  the  formation  of  a  region  termed  the  naso- 
pliaryngecd,  situated  midway  between  the  nasal  fossae 
and  the  pharynx.  It  is  formed  also  by  the  body  of  the 
sphenoid,  the  basilar  process,  and  the  pterygoid  plates. 

The  basilar  process  is  the  usual  locale  of  naso-pha- 
ryngeal  polypi,  and  its  situation  is  readily  recognized 
by  passing  the  finger  behind  the  velum  pendulum  palati, 
which  frequently  has  to  be  divided  in  order  to  remove 
such  growths. 

SUKGICAL  ANATOMY  OF  THE  KEGION  OF  THE 
OKBIT. 

In  the  following  short  description  of  the  orbital  region 
those  parts  only  of  the  eyeball  and  appendages  of  the 
eye  which  are  the  seat  of  the  ordinary  surgical  oper- 
ations are  treated  of.  An  account  of  those  parts  which 
are  contained  within  the  globe,  and  of  the  operative 


THE    REGION    OF    THE    ORBIT.  35 

proceedings  connected  with  them,  are  better  referred  to 
works  devoted  either  to  descriptive  anatomy  or  to  oph- 
thalmic surgery,  as  the  limits  of  the  present  volume 
scarcely  admit  of  so  special  a  subject. 


External  Orbital  Region. 

The  external  orbital  region  comprises  that  of  the  eye- 
lids and  the  lachrymal  apparatus. 

The  eyelids  consist  of  the  following  layers :  The  most 
external  is  the  skin,  which  is  remarkably  thin ;  next  in 
order  is  the  subcutaneous  cellular  tissue,  very  loose,  and 
destitute  of  fat,  continuous  with  that  of  the  forehead, 
and  very  liable  to  infiltration,  if  the  effusion  of  blood 
takes  place  beneath  the  tendon  of  the  occipito-frontalis ; 
then  the  orbicularis  palpebrarum  muscle,  separated  by 
the  palpebral  vessels  from  the  tarsal  ligament  and  car- 
tilages. The  arteries  consist  of  the  palpebral  branches 
of  the  ophthalmic,  which  anastomose  with  the  facial, 
temporal,  infra-orbital,  supra-orbital,  and  lachrymal. 
The  veins,  as  a  rule,  accompany  the  arteries.  The 
nerves  are  derived  from  the  facial,  the  superior  maxil- 
lary of  the  fifth  and  the  third,  which  supplies  also  the 
levator  palpebrse.  The  next  layer  is  formed  of  cellular 
tissue  and  fat,  particularly  developed  at  the  margin  of 
the  lids,  where  it  is  continuous  with  that  of  the  orbit. 
The  most  internal  layer  is  the  palpebral  conjunctiva, 
which  covers  in  the  Meibomian  follicles.  The  tarsal 
cartilage  of  the  upper  lid  is  strengthened  by  the  in- 
sertion into  it  of  the  levator  palpebrse.  The  free  border 
of  the  lids  presents  the  orifices  of  the  Meibomian  and 
ciliary  follicles,  and  their  outer  margin  the  cilia.  The 
Meibomian  glands  are  about  thirty  or  forty  in  number, 


36  SURGICAL    ANATOMY    OF 

having  corresponding  ducts,  on  either  side  of  which 
open  a  number  of  small  cul-de-sacs.  The  office  of  their 
secretion  is  to  prevent  adhesion  of  the  eyelids ;  the  ciliary 
follicles  are  subject  to  dilatation  and  suppuration,  form- 
ing stye.  The  inner  angle  presents  the  tendo-oculi,  the 
inosculation  of  the  angular  and  ophthalmic  arteries  and 
their  veins,  the  lachrymal  sac,  puncta  lachrymalia,  and 
in  the  canthus  the  caruncula  lachry'malis,  having  on  its 
outer  side  the  plica  semilunaris. 

The  conjunctiva,  after  its  reflection  over  the  eyeball, 
becomes  transparent,  and  its  bloodvessels  are  invisible, 
unless  conjunctivitis  is  present.  These  vessels  are  ar- 
ranged as  a  network  over  the  entire  surface  of  the  globe, 
and  can  be  caused  to  slide  over  the  subjacent  cornea  or 
sclerotic,  owing  to  the  cellular  membrane  existing  be- 
tween them.  It  will  be  observed  in  the  inflammatory 
condition,  that  the  direction  of  the  bloodvessels  of  the 
sclerotic  are  arranged  radially,  and  are  pinkish  in  color, 
owing  to  their  lying  in  its  dense  substance,  whereas  the 
conjunctival  vessels  are  scarlet. 

The  lachrymal  apparatus,  which  includes  the  lachry- 
mal gland,  the  lachrymal  ducts,  the  conjunctival  surface 
of  the  eyeball,  the  canalicula,  the  lachrymal  sac  and  its 
duct  (nasal  duct),  is  situated  partially  within  the  orbital 
cavity,  partially  in  the  eyelids,  and  partially  in  the  nose. 

The  lachrymal  gland  lies  in  a  depression  situated  at 
the  external  and  superior  aspect  of  the  orbital  fossa.  It 
is  inclosed  in  a  fibrous  capsule,  and  generally  consists  of 
two  portions — an  orbital,  the  larger,  and  an  anterior  or 
palpebral ;  the  outer  margin  of  the  aponeurosis  of  the 
levator  palpebrse  muscle  forming  a  partial  separation  of 
these  two  portions.  Its  relations  are  as  follows  :  Supe- 
riorly, the  periosteum  of  the  orbit  (dura  mater),  inferiority, 


THE    REGION    OF    THE    ORBIT.  37 

the  eyeball,  and  superior  and  external  recti  muscles ; 
anteriorly  it  is  closely  adherent  to  the  posterior  aspect  of 
the  upper  lid.  Within  it  are  the  lachrymal  branch  of 
the  ophthalmic  artery,  inosculating  with  the  orbital 
branch  of  the  internal  maxillary,  with  their  accompany- 
ing veins ;  the  lachrymal  branch  of  the  ophthalmic  divi- 
sion of  the  fifth  nerve,  which  inosculates  with  the  orbital 
branch  of  the  superior  maxillary  division  of  the  fifth. 
These  structures  enter  at  its  posterior  and  external  mar- 
gin. The  ducts  of  the  lachrymal  gland,  which  are  about 
ten  in  number,  are  so  arranged  that  they  open  in  a  row 
on  to  the  conjunctiva,  where  it  is  reflected  from  the  upper 
lid  to  the  globe. 

The  lachrymal  canals  commence  at  the  puncta  lachry- 
malia,  which  are  seen,  on  everting  the  lid,  as  the  centres 
of  small  eminences,  situated  about  a  quarter  of  an  inch 
from  the  inner  angle,  on  the  inner  aspect  of  the  margin 
of  the  lid.  These  minute  openings  are  kept  in  contact 
with  the  conjunctival  surface  of  the  globe  by  the  action 
of  the  tensor  tarsi,  so  that  they  always  lie  in  the  current 
of  the  tears.  In  each  canaliculus,  immediately  below 
the  punctum,  is  a  small  cul-de-sac,  beyond  which,  after 
inclosing  the  caruncula,  the  canals  join  previous  to  en- 
tering the  lachrymal  sac.  Their  posterior  portion  is 
subconjunctival,  a  circumstance  of  considerable  practical 
value  in  the  operation  of  reinstating  the  course  of  the 
tears  when  from  any  cause  the  orifices  of  the  puncta  do 
not  perform  their  function  of  receiving  the  tears.  That 
portion  which  is  common  to  both  canaliculi  is  bound 
down  by  the  tendo-oculi.  The  process  by  which  the 
continuous  flow  of  tears  between  the  lachrymal  gland 
and  the  nose  is  kept  up,  is  not  entirely  clear ;  it  is  very 

4 


38 


SURGICAL    ANATOMY    OF 


probably  in  a  great  measure  owing  to  suction  caused  by 
exhaustion  in  the  nasal  duct. 


FIG.  3. 


Lachrymal  apparatus  and  nasal  duct.  I.  Lachrymal  sac.  2.  Tendo-^culi. 
3.  Valvular  folds  in  nasal  duct.  4.  Orifice  of  nasal  duct.  5.  Lower  turbinated 
bone.  6.  Inner  wall  of  antrum.  (Bristles  introduced  into  the  punctalachrymalia.) 

The  lachrymal  sac  is  the  superior  dilated  extremity  of 
the  nasal  duct,  and  consists  of  a  tube  of  nbro-elastic  tis- 
sue, lined  with  epithelium,  continuous  through  the 
puncta  with  the  conjunctiva,  and  by  means  of  the  nasal 
duct,  with  the  mucous  membrane  of  the  nose.  It  is 
situated  at  the  internal  angle  of  the  eye,  and  is  lodged 
in  a  hollow  formed  by  the  os  unguis  and  the  nasal  pro- 
cess of  the  superior  maxillary.  It  is  covered  in  by  the 
skin,  subcutaneous  cellular  tissue,  orbicularis  muscle,  by 


THE    REGION    OF    THE    ORBIT.  39 

the  tendo-oculi,  and  the  internal  portion  of  the  palpebral 
aponeurosis.  The  exact  situation  of  the  sac  can  be  felt 
with  the  finger,  and  the  best  landmark  is  the  anterior 
lip  of  the  lachrymal  groove,  surmounted  by  a  small  tu- 
bercle of  bone,  formed  by  the  external  border  of  the 
nasal  process  of  the  superior  maxilla,  or  if  both  the  lids 
be  abducted  from  the  mesial  line,  tension  is  made  on 
the  tendo-oculi,  which  will  show  itself  as  a  flat  cord 
immediately  over  the  sac,  bisecting  it. 

To  introduce  a  Probe  into  the  Nasal  Dud  by  the  punctum 
lachrymale. — It  is  frequently  necessary  to  pass  a  probe 
into  the  nasal  canal  through  the  punctum ;  the  lower 
lid  is  to  be  everted,  when  the  punctum  will  be  seen 
about  two  lines  from  the  inner  angle  on  a  small  papilla. 
The  probe  is  first  to  be  introduced  vertically,  and  pushed 
downwards  for  a  short  distance,  when  the  hand  is  to  be 
depressed,  and  the  probe  pushed  inwards  until  arrested 
by  the  os  unguis,  then  raised  again  vertically ;  when  the 
slightest  pressure  will  cause  it  to  traverse  the  lachrymal 
sac  and  enter  the  nasal  canal,  pushing  it  downwards, 
backwards,  and  inwards. 

When  suppuration  takes  place  in  the  lachrymal  sac, 
and  ulceration  through  the  integument  follows,  lachry- 
mal fistula  is  the  result. 

The  tears  may  be  prevented  passing  into  the  puncta, 
owing  to  their  being  obstructed,  or  to  eversion  of  the 
lid  from  some  cause,  such  as  ectropion,  as  a  result  of  a 
burn  or  other  injury,  or  cicatrization  after  syphilitic 
ulceration. 

Internal  Orbital  Region. 

Dissection. — To  expose  the  contents  of  the  orbit  (the 
skull  cap  having  been  removed)  a  saw  should  be  entered 


40  SURGICAL    ANATOMY    OF 

through  the  frontal  bone,  first  in  a  line  with  the  inner 
angle  and  the  optic  foramen,  and  again  in  a  line  with 
the  outer  angle  and  sphenoidal  fissure ;  a  few  taps  on 
the  orbital  plate  with  a  hammer  will  break  it  through, 
and  the  triangle  of  bone  can  be  readily  tilted  forwards 
by  a  blow  on  the  margin  of  the  skttll ;  the  ring  round 
the  optic  foramen  should  be  retained,  as  the  muscles  are 
attached  to  it. 

Boundaries. — The  bony  walls  of  the  orbit  are  formed 
as  follows : 

The  roof,  concave,  directed  downwards  and  forwards, 
by  the  orbital  plate  of  the  frontal  bone  in  front,  and  by 
the  lesser  wing  of  the  sphenoid  behind.  The  floor,  nearly 
flat,  by  the  malar,  superior  maxillary,  and  orbital  plate 
of  palate.  Outer  watt,  concave,  by  the  greater  wing  of 
sphenoid  and  malar  bone.  Inner  wall,  flat,  by  the  lach- 
rymal, os  planum  of  ethmoid,  and  sphenoid.  Regarding 
the  shape  of  the  orbit  as  nearly  conical,  its  base  is  nearly 
quadrilateral,  and  at  its  several  angles  are  found  the  su- 
tures of  its  component  bones.  At  its  external,  that  of 
the  external  orbital  process  of  the  frontal  with  the  malar ; 
at  its  internal,  that  of  the  frontal  with  the  lachrymal 
and  nasal  process  of  superior  maxilla ;  below,  that  of  the 
malar  with  the  superior  maxilla. 

Its  apex  corresponds  to  the  optic  foramen  and  sphe- 
noidal fissure. 

The  spheno-maxillary  fissure  is  found  on  the  floor  of 
the  orbit.  The  continuity  of  this  fissure  with  the 
spheno-maxillary  fossa  explains  the  protrusion  of  the 
eyeball  from  processes  of  tumors  passing  through  it 
from  the  spheno-maxillary  region. 

Contents. — The  periosteum  of  the  orbit  is  formed  by 
the  dura  mater,  and  enters  the  cavity  by  the  optic  fora- 


THE    REGION    OF    THE    ORBIT.  41 

men  and  anterior  lacerated  fissure.  Each  surface  splits 
into  two  layers — one  continuous  with  the  pericranium  at 
the  upper  margin  of  the  circumference,  or  with  the  peri- 
osteum of  the  face,  and  the  other  which  forms  the  pal- 
pebral  ligament  of  the  lids.  The  muscles  which  act  upon 
the  globe  are  six  in  number — namely,  the  four  recti  and 
two  obliqui,  and  one  muscle  acting  upon  the  upper  lid, 
the  levator  palpebraB.  These  muscles  are  inclosed  in 
fibrous  sheaths  derived  from  the  orbital  aponeurosis.  At 
their  insertion  their  tendons  become  expanded  upon  and 
continuous  with  the  sclerotic.  The  complete  division  of 
the  aponeurotic  sheaths  as  well  as  of  the  tendons  is  nec- 
essary in  the  operation  for  strabismus,  as  these  invest- 
ments if  left  undivided  still  exert  considerable  power 
over  the  globe,  owing  to  their  completely  inclosing  both 
muscle  and  tendon.  The  recti  tendons  are  inserted  into 
the  sclerotic  about  a  quarter  of  an  inch  behind  the  cor- 
nea. The  upper  and  lower  eyelids  are  united  to  the 
sheaths  of  the  superior  and  inferior  recti  muscles  by  an 
oifset  of  the  palpebral  aponeurosis,  forming  the  posterior 
boundaries  of  the  superior  and  inferior  oculo-palpebral 
cul-de-sacs.  A  knowledge  of  the  arrangement  of  these 
aponeurotic  expansions  and  of  their  situations  is  of  some 
considerable  importance  in  the  diagnosis  of  intra-orbital 
injury  or  disease,  as  by  their  attachment  and  situation 
they  facilitate  or  impede  the  course  taken  by  blood  or 
pus.  Ecchymosis  beneath  the  conjunctiva  is  almost  in- 
variably a  symptom  of  fracture  of  the  roof  of  the  orbit 
after  injury  of  the  head. 

The  eyeball  and  its  vessels  and  nerves  lie  in  a  mass  of 
fat  and  cellular  tissue,  which  serves  as  a  cushion  for  the 
optic  nerve  and  for  the  globe  in  its  various  movements, 
and  as  a  support  for  its  accessory  structures.  This  eel- 


42  SURGICAL    ANATOMY    OF 

lulo-fatty  mass  is  continuous  with  the  cranial  cellular 
tissue,  and  with  that  of  the  zygomatic  and  spheno-maxil- 
lary  fossae. 


FIG.  4. 


Aponeuroses  of  orbit.  (Altered  from  BERAUD.)  1.  Dura  mater.  2.  Prolonga- 
tion of  dura  mater  into  the  posterior  palatine  canal.  3.  Superior  rectus  in- 
closed in  its  sheath.  4.  Optic  nerve.  5.  Inferior  rectus  in  its  sheath.  6.  Process 
of  aponeurosis  of  inferior  oblique  attached  to  the  palpebral  aponeurosis.  7.  In- 
ferior oculo-palpebral  cul-de-sac.  8.  Inferior  tarsal  cartilage.  9.  Ocular  portion 
of  orbito-ocular  aponeurosis.  10.  Superior  tarsal  cartilage.  11.  Palpebral  apon- 
eurosis. 12.  Superior  oculo-palpebral  cul-de-sac.  13.  Process  of  aponeurosis  of 
superior  oblique  attached  to  the  palpebral  aponeurosis.  14.  Periosteum  of  frontal 
bone  continuous  with  that  of  the  orbit. 


The  arteries  are  derived  from  the  ophthalmic  branch 
of  the  internal  carotid,  which  enters  the  optic  foramen 
below  the  nerve,  and  forms  free  anastomoses  with  the 
temporal,  facial,  and  internal  maxillary. 

The  veins  generally  accompany  the  arteries,  and  termi- 
nate in  a  large  vein,  the  ophthalmic,  unprovided  with 
valves,  which,  after  being  formed  both  without  and 
within  the  orbit,  passes  as  a  trunk  between  the  two  heads 
of  the  external  rectus  muscle,  and  enlarges  into  the 
cavernous  sinus. 


THE    REGION    OF    THE    ORBIT.  43 

The  nerves  are — the  optic,  the  third,  the  fourth,  the 
ophthalmic  division  of  the  fifth  and  the  sixth,  with  their 
branches,  and  from  the  lenticular  ganglion  are  given  off 
the  ciliary  (short).  Paralysis  of  the  third  nerve  or 
motor-oculi,  causes  ptosis,  or  a  dropping  of  the  upper 
lid,  external  strabismus,  dilatation,  and  immobility 
of  the  pupil.  Paralysis  of  the  fourth  nerve,  or  patheti- 
cus,  causes  impossibility  of  rotation  of  the  eyeball,  and 
diplopia;  in  paralysis  of  the  sixth,  or  abducens,  the  eye- 
ball is  turned  inwards. 

Relations  of  Parts  within  the  Orbit. — A  good  idea  of 
the  actual  relations  of  the  contents  of  the  orbital  cavity 
looked  upon  as  a  cone  may  be  obtained  by  regarding  the 
eyeball  and  optic  nerve  as  occupying  very  nearly  its  axis, 
and  the  muscles,  vessels,  and  nerves  as  placed  superiorly, 
inferiorly,  externally,  and  internally  to  them.  A  needle 
passing  through  the  axis  of  the  eyeball  from  its  anterior 
surface  backwards  would  traverse  successively — (1)  the 
ocular  conjunctiva;  (2)  the  four  layers  of  the  cornea — 
viz.,  anterior  elastic  lamina,  the  cornea  proper,  the  pos- 
terior elastic  lamina,  the  posterior  epithelium;  (3)  the  an- 
terior chamber ;  (4)  the  pupil ;  (5)  the  anterior  layer  of  the 
capsule  of  the  lens;  (6)  the  lens;  (7)  the  posterior  layer 
of  the  capsule  of  the  lens;  (8)  the  anterior  portion  of 
the  hyaline  membrane;  (9)  the  vitreous  humor;  (10) 
the  posterior  portion  of  the  hyaline  membrane;  (11)  the 
three  layers  of  the  retina — viz.  («),  Jacob's  membrane 
(rods  and  cones);  (ft)  the  granular  layer;  (^)  the  fibrous 
layer;  (12)  the  choroid;  (13)  the  sclerotic. 

The  relations  of  the  globe  and  optic  nerve,  considered 
as  occupying  the  axis  of  the  orbital  cavity,  successively 
exposed  by  dissection,  from  either  surface  inwards,  would 
be  as  follows : 


44  SURGICAL    ANATOMY    OP 

Superiorly,  from  above  downwards  (omitting  the  dura 
mater):  (1)  The  frontal  vessels  and  nerves,  and  behind 
in  the  same  plane  the  fourth  nerve ;  (2)  the  levator  pal- 
pebrse  muscle;  (3)  the  rectus  superior;  (4)  the  superior 
set  of  the  muscular  branches  of  the  ophthalmic  artery, 
and  the  superior  division  of  the  third  nerve;  (5)  the 
nasal  nerve  and  ophthalmic  artery,  and  the  ciliary  ves- 
sels and  nerves. 

Inferiorly,  from  below  upwards:  (1)  The  inferior 
rectus,  and  the  inferior  oblique  muscles;  (2)  the  inferior 
division  of  the  third  nerve,  and  its  branch  to  the  lenticu- 
lar ganglion;  (3)  the  inferior  set  of  muscular  vessels. 

Internally,  from  within  outwards:  (1)  The  superior 
oblique  and  internal  rectus  muscles.  (2)  The  termina- 
tion of  the  fourth  nerve,  the  nasal  nerve,  the  ophthalmic 
artery  and  vein,  and  the  anterior  ethmoidal  artery. 

Externally,  from  without  inwards:  (1)  The  lachry- 
mal vessels  and  nerve,  and  the  lachrymal  gland.  (2) 
The  external  rectus  muscle,  between  the  two  heads  of 
which  pass,  both  divisions  of  the  third  nerve,  the  nasal 
of  the  fifth,  the  sixth  nerve,  and  the  ophthalmic  vein. 
(3)  The  nasal  nerve,  lenticular  ganglion,  and  ophthal- 
mic artery. 

The  structures  divided  in  the  operation  of  extirpation  of 
the  globe  are — the  conjunctiva,  the  subconjunctival  tissue, 
the  tendons  of  the  recti  and  obliqui  with  their  aponeu- 
rotic  sheaths,  the  optjc  nerve,  and  the  long  and  short 
ciliary  vessels  and  nerves. 

The  structures  divided  in  the  operation  for  strabismus 
are — the  conjunctiva,  subconjunctival  tissue,  and  rectus 
tendon  with  its  aponeurotic  sheath. 


THE    SUPERIOR    MAXILLARY    REGION.  45 


SURGICAL  ANATOMY  OF  THE  SUPERIOR  MAXIL- 
LARY REGION. 

This  region  may  be  regarded  as  that  occupied  by  the 
superior  maxilla  and  the  tissues  covering  it.  The 
superior  maxilla  is  a  bone  of  great  surgical  interest,  on 
account  of  the  many  diseases  to  which  it  is  liable ;  hence 
its  position,  relations,  and  connections  are  of  the  highest 
practical  importance. 

The  structures  exposed  in  their  order  on  dissecting  down 
upon  the  superior  maxilla  are — the  skin  and  superficial 
fascia ;  the  lower  fibres  of  the  orbicularis  palpebrarum ; 
the  facial  and  infra-orbital  vessels  and  nerves ;  the  zygo- 
matici  and  the  levator  labii  superioris;  Steno's  duct; 
the  transverse  facial  artery ;  the  buccal  vessels  and 
nerves ;  lymphatics,  and  the  buccinator  muscle.  In  the 
hollow  between  the  anterior  border  of  the  masseter  and 
the  buccinator  muscle  is  a  large  quantity  of  fat  and 
cellular  tissue,  which  contributes,  either  by  its  excess  or 
deficiency,  to  the  general  contour  of  the  face. 

Articulations  of  the  Superior  Maxilla. — Articulating 
with  its  fellow,  it  forms  the  whole  of  the  upper  jaw  ;  be- 
sides this,  it  articulates  with  the  frontal,  ethmoid,  nasal, 
inferior  turbinated,  palate,  vomer,  malar,  and  lachrymal. 
The  sutures  it  forms  with  those  bones  which  enter  into 
the  formation  of  the  face  are  very  strong  and  difficult  to 
separate,  so  much  so,  that  in  excision  it  will  generally 
be  found  more  satisfactory  to  divide  it  or  its  associate 
near  to  the  articulation  than  to  attempt  to  wrench  them 
apart  at  the  sutures.  The  processes  requiring  division 
in  its  extirpation  are  the  palatine,  nasal,  and  malar. 
Each  bone  assists  in  the  formation  of  three  cavities, — the 
mouth,  nose,  and  orbit ;  of  two  fossae,  the  zygomatic  and 


46 


SURGICAL    ANATOMY    OF 


spheno- maxillary;  and  of  two  fissures,  the  spheno-max- 
illary  and  ptery go-maxillary.  The  relation  of  these 
fissures  and  cavities  to  the  body  of  the  bone  is  of  great 
importance  in  the  process  of  its  removal.  The  apex  of 
the  antrum  corresponds  on  the  face  to  its  malar  process; 
the  base  of  which  looks  inwards  to  the  outer  wall  of  the 
nose;  and  its  roof  is  formed  by  the  orbital  plate,  and  its 

FIG.  5. 


FIG.  6. 


FIG.  7. 


Fig.  5  shows  the  defective  development  of  the  superior  maxillary  bones,  from 
a  frjetus  seven  months  old;  and  Figs.  6,  7  show  the  central  mass  formed  of  two 
portions.  In  these  cases,  particularly  in  Fig.  5,  the  fact  of  the  central  portion 
being  composed  of  two  intermaxillary  bones  is  well  seen,  the  fissure  being  in  the 
mesial  line  exactly  under  the  nostril.  (FERGUSSON.) 

floor  by  the  alveolar  process.  The  walls  of  the  antrum 
are  very  thin,  so  that  growths  or  collections  of  fluid 
readily  cause  a  bulging  of  its  parietes  and  protrusions 
into  neighboring  cavities  or  fissures.  The  fangs  of  the 
first  and  second  molar  teeth  project  into  its  floor,  hence 
the  importance  of  extracting  one  of  these  teeth  and  per- 


THE    SUPERIOR    MAXILLARY    REGION.  47 

forating  its  socket  before  interfering  with  any  doubtful 
tumor  connected  with  the  cavity. 

Besides  the  growths  which  are  developed  in  the  an- 
trum,  the  bone  is  surgically  interesting  as  being  subject 
to  an  arrest  in  its  development,  known  as  fissured  or  deft, 
palate,  frequently  associated  with  a  similar  one  in  its 
appendage,  the  upper  lip,  termed  hare-lip.  During  its 
development  that  portion  which  carries  the  incisor  teeth 
is  a  separate  segment,  and  if  this  segment  be  ununited 
the  result  is  a  deep  fissure,  extending  backwards  into  the 
palate;  occasionally  these  segments  in  both  bones  are 
thus  disconnected,  in  which  case  they  both  hang  from 
the  end  of  the  vomer,  leaving  a  chasm  in  the  roof  of  the 
mouth,  a  condition  usually  associated  with  a  double 
hare-lip. 

Structures  divided  in  Excision  of  the  Upper  Jawbone. — 
Supposing  the  incision  through  the  upper  lip,  along  the 
ala  of  the  nose,  towards  the  inner  angle  of  the  orbit  and 
along  its  lower  margin  to  be  adopted ;  first  are  the  tis- 
sues composing  the  upper  lip — viz.,  the  integument,  the 
orbicularis  oris  muscle,  the  cellular  tissue  containing  the 
labial  glands,  the  coronary  vessels,  facial,  and  branches 
of  the  second  division  of  fifth  nerves,  and  the  mucous 
membrane.  Next  carrying  the  incision  along  the  ala 
and  side  of  the  nose,  the  integument,  fascia,  levator  labii 
superioris  alseque  nasi,  with  its  aponeurosis,  the  angular 
vessels  and  branches  of  the  infra-orbital  and  facial  nerves. 
The  incision  along  the  lower  border  of  the  orbit  divides 
the  integument,  aponeurosis,  orbicularis  palpebrarum 
muscle,  the  vessels  of  the  lower  eyelid,  and  the  orbital 
fascia ;  and  if  a  portion  of  the  floor  of  the  orbit  be  re- 
moved, the  tendon  of  the  inferior  oblique,  and  by  turn- 
ing back  the  flap  inclosed  by  these  incisions,  the  attach- 


48        SURGICAL    ANATOMY    OF    THE    REGION    OF 

merits  to  the  bone  of  the  following  muscles, — orbicularis, 
levator  labii  superioris  et  alse  nasi,  levator  labii  superioris, 
compressor  naris,  depressor  labii  superioris,  levator  an- 
guli  oris,  buccinator,  infra-orbital  vessels  and  nerve,  and 
facial  vessels  and  nerves.  The  advantage  of  this  method 
of  external  incision  is  that  the  vessels  are  divided  near 
their  termination,  and  not  through  their  larger  branches, 
and  the  duct  of  the  parotid  is  left  entire,  without  the 
risk  of  salivary  fistula,  besides  leaving  an  almost  un- 
noticeable  cicatrix,  by  following  the  natural  furrows  of 
the  face. 

In  the  second  stage  of  the  operation,  an  incisor  tooth 
being  extracted,  the  gum,  alveolar  process,  and  structures 
forming  the  hard  palate — malar  and  nasal  processes,  with 
a  portion  of  the  floor  of  the  orbit.  In  the  subsequent 
dislocation  of  the  bone,  the  internal  maxillary  artery, 
with  its  vein  and  the  branches  after  they  have  gained 
the  pterygo-maxillary  fossa,  and  the  posterior  palatine 
nerves  are  divided. 

SURGICAL  ANATOMY  OF  THE  REGION  OF  THE  SOFT 
PALATE  AND  TONSIL. 

The  soft  palate,  which  is  suspended  obliquely  from 
before  backwards  "from  the  posterior  border  of  the  pala- 
tine arch,  or  hard  palate,  is  a  curtain  consisting  of  mucous 
membrane,  muscular  and  fibrous  tissue,  vessels  and  nerves, 
forming  an  incomplete  septum  between  the  nasal  and 
buccal  cavities,  serving  to  prevent  the  food  from  passing 
upwards  into  the  nasal  fossae,  helping  to  push  it  down- 
wards into  the  pharynx  during  deglutition,  and  also  act- 
ing upon  the  quality  of  the  voice.  Its  movements  are 
elevation,  depression,  and  transverse  tension.  It  is  con- 
cave anteriorly,  and  its  inferior  anterior  border  presents 


THE    SOFT    PALATE    AND    TONSIL.  49 

two  semilunar  margins,  the  edges  of  which  pass  down- 
wards to  the  sides  of  the  tongue,  united  in  a  central  raphe, 
from  which  depends  a  prolongation,  the  uvula. 

In  structure  the  soft  palate  consists  anteriorly  and  in- 
feriorly  of  a  mucous  membrane,  thickly  studded  with 
muciparous  glands,  continuous  with  that  of  the  posterior 
region  of  the  mouth,  and  posteriorly  and  superiorly  of  a 
second  membrane,  continuous  with  that  of  the  naso- 
pharyngeal  region.  Between  these  mucous  layers  is  a 
musculo-tendinous  one,  consisting  of  portions  of  the  fol- 
lowing pairs  of  intrinsic  muscles, — the  levatores  palati 
and  the  tensores  or  circumflexi  palati ;  and  of  extrinsic 
muscles,  the  palato-glossi  and  the  palato-pharyngei. 
Some  delicate  muscular  fibres  are  to  be  found  in  the 
uvula.  The  order  in  which  the  structures  enter  into  the 
formation  of  the  velum  is  as  follows :  From  before  back- 
wards, (1)  the  anterior  layer  of  mucous  membrane ;  (2)  the 
aponeurosis  of  the  tensores  palati,  with  which  is  blended 
the  attachments  of  the  palato-glossi  and  palato-pharyngei ; 
(3)  the  levatores  palati,  uniting  in  the  median  raphe  ;  (4) 
the  posterior  layer  of  mucous  membrane. 

The  pillars  of  the  fauces  are  formed  by  the  divergence 
of  the  palato-glossus  and  palato-pharyngeus,  and  include 
a  triangular  interval,  the  base  being  downwards,  in  which 
is  situated  the  tonsil.  The  posterior  pillars  formed  by 
the  palato-pharyngei  are  nearer  each  other  than  the 
anterior,  formed  by  the  palato-glossi. 

The  space  between  the  palatine  arches  of  both  sides  is 
called  the  isthmus  of  the  fauces,  and  is  bounded  above  by 
the  free  margin  of  the  palate,  below  by  the  dorsum  of 
the  tongue,  and  laterally  by  the  pillars  of  the  fauces  and 
tonsils. 

A  correct  knowledge  of  the  attachments  and  actions 


50        SURGICAL    ANATOMY    OF    THE    REGION    OF 

of  the  muscles  of  the  soft  palate  is  of  great  importance, 
with  a  view  to  the  successful  performance  of  operations 
for  the  relief  of  fissures  or  clefts  in  it. 

The  fibres  of  the  levator  palati  pass  downward  and 
inward,  spreading  out  on  the  velum  as  a  layer,  which  is 
embraced  by  the  two  planes  of  fibres  of  the  palato- 
pharyngeus  and  unites  with  its  fellow  of  the  opposite 
side.  The  tensor  palati  ends  in  a  tendon,  which  is  re- 
flected horizontally  round  the  hamular  process  of  the 
sphenoid,  and  after  spreading  out  is  inserted  into  the 
aponeurosis  of  the  velum,  below  the  levator  palati,  and 


This  figure  represents  the  posterior  nares  and  upper  surface  of  the  soft  palate. 
a.  Levator  palati ;  the  dark  line  shows  where  it  should  be  cut  across,  b.  The 
inner  bundle  of  fibres  of  the  palato-pharyngeus ;  the  dark  line  indicates  its  place 
of  division,  c.  The  palato-glossus,  with  the  mark  for  incision,  when  necessary. 
d.  The  tensor  palati,  in  relation  with  the  cartilaginous  extremity  of  the  Eusta- 
chian  tube,  e.  The  posterior  extremity  of  the  inferior  turbinated  bone.  /.  The 
septum,  g,  g.  The  uvula  on  each  side  stretched  apart.  (FEHGUSSON.) 

into  the  palate  bone.  The  position  of  the  hamular  pro- 
cess, an  important  guide  in  the  performance  of  operations, 
can  be  felt  distinctly  in  the  substance  of  the  soft  palate, 
internal  to  and  slightly  posterior  to  the  last  molar  tooth. 


THE    SOFT    PALATE    AND    TONSIL.  51 

The  action  of  the  palatine  muscles  upon  a  fissure  ex- 
isting in  the  velum  would  obviously  produce  a  separa- 
tion of  its  margins,  and  it  has  been  shown  that  the  mus- 
cular action  by  which  these  margins  are  brought  together 
is  caused  by  the  upper  semicircular  border  of  the  superior 
constrictor  of  the  pharynx,  and  that  the  muscles  to  be 
divided  in  the  operation  of  staphyloraphy  or  stitching  up 
the  fissure,  are  the  levatores  palati  and  the  palato-pha- 
ryngei,  the  upper  expanded  fasciculi  of  which  are  divided 
into  two  parts  by  the  levatores  palati,  and  if  necessary 
the  palato-glossi.  (Fergusson.) 

The  levator  palati  is  to  be  divided  on  both  sides  by 
putting  the  undeveloped  velum  upon  the  stretch,  when 
a  double-edged  knife  is  passed  through  the  soft  palate, 
just  on  the  inner  side  of  the  hamular  process,  and  above 
the  line  of  the  levator  palati. 

Another  method  of  dividing  the  levator  palati  is  by 
passing  a  knife  curved  on  the  flat  through  the  fissure 
and  behind  the  flap,  its  edge  making  an  incision  half  an 
inch  long,  half  way  between  the  hamular  process  and  the 
orifice  of  the  Eustachian  tube,  and  perpendicular  to  a  line 
drawn  between  them. 

The  palato-pharyngeus  is  to  be  divided  by  cutting 
through  the  posterior  pillars  just  below  the  tonsil.  Occa- 
sionally the  palato-glossus  requires  division. 

The  tonsils  or  amygdalce  are  two  small  glandular  bodies, 
varying  in  size  in  different  individuals,  situated  between 
the  anterior  and  posterior  pillars  of  the  fauces ;  they  are 
in  relation,  externally  with  the  superior  constrictor,  and 
by  it  separated  from  the  internal  carotid  and  ascending 
pharyngeal  vessels ;  below  they  rest  on  the  side  of  the 
base  of  the  tongue.  The  position  of  the  tonsil  corre- 
sponds with  the  angle  of  the  inferior  maxilla,  at  a  point 


52  SURGICAL    ANATOMY    OF 

nearly  opposite  the  root  of  the  alveolar  process  of  the 
second  molar  tooth.  Under  certain  circumstances  the 
carotid  artery  is  in  danger  of  being  wounded,  such  as  in 
excision  of  the  gland  or  the  evacuation  of  pus,  when  by 
its  enlargement  it  is  brought  still  more  closely  into  con- 
nection with  the  vessels,  but  if  the  precaution  be  taken 
of  lifting  it  well  from  its  bed  forwards  and  inwards 
before  the  knife  is  applied  for  its  removal,  the  risk  in 

FIG.  9. 


Relation  of  the  right  tonsil  viewed  laterally,  the  half  of  the  lower  jaw  having 
been  removed.  1.  Steno's  duct  crossing  the  masseter  and  opening  into  the  buccal 
cavity.  2.  Ascending  pharyngeal  artery.  3.  Stylo-pharyngeus  muscle.  4.  Pharyn- 
geal  branch  of  vagus.  5.  Glosso-pharyngeal  nerve.  (Behind  which  is  seen  the 
internal  carotid  artery.)  6.  Tonsil  lying  between  the  pillars  of  the  fauces.  7. 
Stylo-glossus  muscle,  hooked  aside.  8.  Wharton's  duct.  9.  Sublingual  gland. 
10.  Superior  lobe  of  submaxillary  gland.  11.  Stylo-hyoid  muscle,  hooked  aside. 
12.  Gustatory  nerve.  13.  Submaxillary  gland.  14.  Spinal  accessory  nerve.  15. 
Hypoglossal  nerve. 


this  instance  is  avoided ;  and  in  the  latter,  care  must  be 
taken  not  to  push  the  knife  forwards  in  the  line  of  the 
angle  of  the  jaw,  but  backwards  into  the  tumor  towards 


THE    PAROTID    REGION. 


53 


the  spine,  and  so  allow  it  to  cut  its  way  out,  towards  the 
median  line  of  the  body. 

The  vessels  of  this  region  are  derived  from  the  ascend- 
ing pharyngeal  of  the  external  carotid,  the  ascending 
palatine  and  tonsillitic  of  the  facial,  the  dorsalis  linguae 


FIG.  10. 


Sketch  of  the  relations  of  the  left  tonsil  viewed  from  above.  1.  Superior  cer- 
vical ganglion.  2.  Internal  carotid  artery  and  jugular  vein.  3.  Digastric  muscle. 
4.  External  carotid  artery.  5.  Glosso-pharyngeal  nerve  (drawn  too  thick).  6. 
Stylo-pharyngeus  muscle.  7.  Stylo-glossus  muscle.  8.  The  tonsil.  9.  Section  of 
the  pharynx  and  its  mucous  membrane. 

of  the  lingual,  and  the  descending  palatine  of  the  inter- 
nal maxillary ;  and  the  nerves,  from  the  glosso-pharyn- 
geal  and  Meckel's  ganglion. 


SURGICAL  ANATOMY  OF  THE  PAROTID  REGION. 

The  boundaries  of  the  parotid  region  are  somewhat 
difficult  of  definition,  partly  on  account  of  the  irregu- 
larity of  the  gland,  and  partly  on  account  of  its  belong- 
ing both  to  the  cranium  and  to  the  neck.  The  follow- 
ing appear  to  be  the  simplest :  In  front,  the  posterior 

5 


54  SURGICAL    ANATOMY    OF 

border  of  the  raraus  of  the  jaw ;  behind,  the  mastoid 
process  of  the  temporal  bone,  the  cartilage  of  the  ear 
and  the  edges  of  the  sterno-mastoid  and  digastric  mus- 
cles ;  above,  the  zygomatic  arch ;  and  below,  an  imagi- 
nary line  drawn  horizontally  backwards  and  inwards 
from  the  angle  of  the  jaw  to  the  styloid  process,  by  the 
stylo-hyoid  and  stylo-maxillary  ligaments,  and  the  pro- 
cess of  cervical  fascia  passing  from  the  sterno-mastoid  to 
the  jaw.  The  dimensions  of  this  region  'obviously  vary 
with  the  several  movements  of  the  lower  jaw ;  more- 
over, there  are  certain  differences  in  its  size  with  respect 
to  the  age  of  the  individual ;  thus,  in  the  infant,  the  re- 
gion is  broader  in  proportion  below,  on  account  of  the 
obliquity  of  the  jaw  and  the  non-development  of  its 
angle,  and  bulges  externally,  on  account  of  the  quantity 
of  fat  and  lymphatics  contained  within  it ;  again,  in  old 
age,  in  the  edentulous  state,  the  base  of  the  region  be- 
comes broader,  owing  to  the  falling  forward  of  the  jaw. 

Dissection. — On  removing  the  integument  covering 
the  parotid  gland,  it  will  be  seen  to  be  enveloped  in  an 
incomplete  capsule  derived  from  the  cervical  fascia 
which  separates  it  from  neighboring  structures. 

The  relations  and  connections  of  the  parotid  gland  are, 
externally  and  superficially  the  lymphatics,  the  platysma 
myoides,  some  few  branches  of  the  superficial  cervical 
plexus,  and  the  integument;  anteriorly,  the  posterior 
border  of  the  ramus  of  the  jaw,  the  external  and  inter- 
nal pterygoid  muscles,  between  which  lies  a  process  of 
the  gland ;  inferiorly  and  posteriorly,  the  mastoid  pro- 
cess, the  sterno-mastoid,  posterior  belly  of  digastric, 
styloid  muscles,  transverse  process  of  atlas,  internal 
jugular  vein,  internal  carotid  artery,  eighth  pair  of 


THE    PAROTID    REGION.  55 

nerves,   hypoglossal   nerve,   and    the   superior   cervical 
ganglion  of  the  sympathetic. 

The  substance  of  the  gland  contains  so  many  impor- 
tant structures  that  operative  proceedings  connected 
with  it  are  rendered  excessively  difficult  and  hazardous. 
The  external  carotid  artery  traverses  its  posterior  part, 
giving  off  its  anterior  and  posterior  auricular  and  super- 
ficial temporal  branches.  Behind  the  external  carotid 
is  the  external  jugular  vein,  which  receives  numerous 
branches  in  its  substance.  A  quantity  of  lymphatics 


FIG.  11. 


Sketch  of  the  deep  relations  of  the  right  parotid  gland  (the  gland  itself  has 
been  removed  and  the  ramus  of  the  lower  jaw  drawn  forward).  1.  Remains  of 
aponeurosis  of  gland.  2.  Digastric  muscle.  3.  Stylo-hyoid  muscle.  4  Stylo- 
pharyngeus  (drawn  aside).  5.  Stylo-glossus  muscle.  6.  Stylo-maxillary  liga- 
ment. 7.  External  jugular  vein.  8.  External  carotid.  9.  Lingual  artery  seen 
through  an  opening  in  the  aponeurosis.  10.  Posterior  auricular  artery.  11. 
Transverse  facial  artery.  12.  Internal  maxillary  artery.  13.  Anterior  and 
middle  temporal  arteries.  14.  Internal  carotid.  15.  Hypoglossal  nerve.  16. 
Glosso-pharyngeal  nerve.  17.  Trunk  of  facial  nerve.  19.  Steno's  duct. 

are  also  found  in  relation  with  the  gland.  The  super- 
ficial lymphatic  ganglia  receive  the  vessels  of  the  scalp ; 
those  within  the  gland,  the  vessels  from  the  eyebrows, 


56  SURGICAL    ANATOMY    OF 

lids,  and  cheeks ;  and  the  deepest,  which  accompany  the 
internal  carotid,  are  the  vessels  of  the  temporal  and 
maxillary  regions.  The  facial  nerve,  after  it  has  passed 
through  the  stylo-mastoid  foramen,  enters  the  posterior 
and  inferior  portion  of  the  parotid,  and  thence  spreads 
out  into  several  large  plexiform  branches  (pes  anserinus), 
after  which  it  ramifies  amongst  the  muscles  of  the  face. 
The  auriculo-temporal  branch  of  the  inferior  maxillary 
nerve  also  enters  the  gland  after  having  passed  behind 
the  neck  of  the  jaw,  and  forms  inosculations  with  the 
facial.  The  auriculo-parotidean  branch  of  the  cervical 
plexus  enters  the  gland  anteriorly  and  inferiorly,  inos- 
culating with  the  preceding. 

The  existence  of  the  tough  fibrous  investment  which 
incloses  the  gland  almost  entirely  and  binds  it  so  tightly 
in  its  place,  accounts  for  the  intense  pain  in  inflamma- 
tion, as  in  parotitis,  or  abscess.  Wounds,  or  the  results 
of  abscess  in  the  substance  of  the  gland,  may  give  rise 
to  salivary  fistulce,  which  are  frequently  very  trouble- 
some to  close;  and  in  the  removal  of  tumors  connected 
with  it,  or  in  its  neighborhood,  there  is,  of  course,  great 
danger  of  severe  hemorrhage,  and  of  wounding  the  facial 
nerve,  thus  causing  paralysis  of  the  facial  muscles.  The 
surgical  relations  of  the  duct  of  the  parotid  have  been 
already  considered  (vide  Face).  The  external  carotid 
may  be  compressed  against  the  styloid  process  in  the 
adult,  but  it  is  impossible  in  the  child,  owing  to  the  un- 
developed state  of  that  portion  of  the  bone. 

SURGICAL  ANATOMY  OF  THE  PTERYGO-MAXIL-. 
LAKY  REGION. 

The  surf  ace  markings  of  this  region  are  the  bony  promi- 
nences of  the  zygoma  and  lower  jaw,  and  the  contour  of 


THE    PTERYGO-MAXILLARY    REGION.  57 

the  masseter  muscle,  the  tendinous  intersections  of  which 
are  very  evident  during  its  action.  If  the  finger  be 
passed  into  the  mouth,  the  superior  border  of  the  lower 
jaw,  the  internal  aspect  of  its  ramus,  and  its  anterior 
border  can  be  felt;  and  if  the  jaws  are  apart,  its  coro- 
noid  process;  the  mutual  relations  of  which  should  be 
carefully  noticed. 

Dissection. — The  superficial  dissection  of  the  face  being 
completed,  and  the  facial  nerve,  the  transverse  facial 
vessels,  with  the  duct  of  the  parotid,  cut  and  turned 
forwards,  that  portion  of  the  parotid  which  lies  upon  the 
masseter  is  to  be  turned  back  towards  the  ear,  and  the 
masseter  itself  exposed.  Two  sets  of  fibres  will  be  seen 
— the  anterior  forming  the  greater  bulk  of  the  muscle, 
and  behind  and  below  these  some  oblique  fibres,  which 
are  inserted  beneath  the  anterior.  The  origin  of  these 
fibres  is  on  the  under  and  inner  surface  of  the  zygomatic 
arch.  It  is  to  be  noticed  that  the  zygoma  is  entirely 
subcutaneous.  Next,  the  extremities  of  this  process  are 
to  be  divided  with  a  saw,  and  the  included  portion  of 
bone  with  the  origin  of  the  muscle  turned  downwards 
upon  the  ramus  of  the  jaw,  noticing  the  attachment  of 
the  temporal  fascia  to  its  upper  border,  and  taking  care 
not  to  divide  the  masseteric  nerve  and  artery,  which 
enter  the  under  and  upper  aspect  of  the  masseter  through 
the  sigmoid  notch,  or  to  injure  the  external  lateral  liga- 
ment of  the  temporo-maxillary  articulation.  The  ramus 
of  the  jaw  is  next  to  be  divided  transversely,  about 
three-quarters  of  an  inch  below  the  notch,  taking  care 
not  to  injure  the  inferior  dental  vessels  and  nerve  which 
enter  the  bone  on  its  inner  surface.  The  neck  of  the 
condyle  should  then  be  nipped  through,  and  the  portion 
of  bone  (including  the  coronoid  process  and  a  part  of 


58  SURGICAL    ANATOMY    OF 

the  raraus)  carefully  lifted  up,  with  the  attached  tem- 
poral muscle;  some  fibres  of  this  muscle  must  be  di- 
vided in  order  to  do  this,  and  as  the  buccal  nerve  and 
artery  usually  lie  immediately  beneath  them,  some  cau- 
tion is  necessary  in  order  to  avoid  their  division. 

Contents. — Immediately  beneath  the  bone  thus  raised, 
are  seen  a  portion  of  the  internal  maxillary  artery,  the 
external  pterygoid  muscle,  and  emerging  from  its  lower 
border  the  gustatory  branch  of  the  third  division  of  the 
fifth,  the  mylo-hyoidean  branch  of  the  inferior  dental 
nerve,  part  of  the  internal  pterygoid  muscle,  the  trunk  of 
the  inferior  dental  and  deep  temporal  nerves,  the  inter- 
nal lateral  ligament  of  the  temporo-maxillary  articula- 
tion, and  in  front  of  the  internal  pterygoid  the  posterior 
portion  of  the  buccinator. 

The  vessels  of  this  region  are,  in  the  superficial  dissec- 
tion, the  transverse  facial  or  external  maxillary,  which 
arises  from  the  external  carotid  in  the  parotid  gland, 
just  above  the  angle  of  the  jaw,  and  in  relation  with  the 
portio  dura  and  Steno's  duct,  crosses  the  masseter  a  lit- 
tle below  the  zygoma. 

In  the  deep  dissection  the  internal  maxillary  artery 
commences  at  the  outer  border  of  the  neck  of  the  jaw- 
bone, lying  in  the  first  part  of  its  course  behind  it,  and 
in  front  of  the  internal  lateral  ligament;  it  then  curves 
forwards  to  the  lower  border  of  the  external  pterygoid 
muscle,  lying  on  it,  and,  generally  disappearing  between 
its  two  heads,  passes  into  the  pterygo-maxillary  fossa. 
The  trunk  of  this  vessel  or  its  descending  branch,  the 
inferior  dental,  are  usually  divided  in  resection  of  the 
bone.  Its  tortuous  course  and  variable  position  render 
it  the  more  liable  to  be  wounded. 

The  nerves  are  derived  from  the  inferior  maxillary  di- 


THE    PTERYGO-MAX1LLARY    REGION.  59 

vision  of  the  fifth,  which  passes  into  the  region  through 
the  foramen  ovale  of  the  sphenoid.  The  nerve  consists 
of  two  portions — a  muscular,  distributed  to  all  the  mus- 
cles of  mastication  —  viz.,  masseteric,  deep  temporal, 
pterygoid,  buccal ;  and  a  sensory — the  inferior  dental, 
auriculo-temporal,  and  gustatory.  The  relations  of  the 
salivary  glands  to  the  body  of  the  inferior  maxilla  are 
of  considerable  importance  with  regard  to  operations  on 
it.  The  parotid  envelops  the  posterior  border  of  its 
ramus,  and  passes  behind  its  neck  as  far  as  the  styloid 
process  of  the  temporal  bone;  the  submaxillary  gland  is 
partially  lodged  in  a  fossa,  below  the  attachment  of  the 
mylo-hyoid,  which  during  flexion  of  the  head  is  con- 
cealed beneath,  and  in  extension  is  considerably  disen- 
gaged from  the  bone — facts  to  be  considered  in  opera- 
tions in  the  region  of  the  upper  part  of  the  neck. 

The  temporo-maxiilary  articulation  is  formed  between 
the  glenoid  cavity  of  the  temporal  bone  and  the  condyle 
of  the  lower  jaw.  Interposed  between  the  bones  is  a 
biconcave  interarticular  fibro-cartilage,  above  and  below 
which  is  a  synovial  membrane.  The  external  portion  of 
the  circumference  of  this  cartilage  is  connected  with  the 
external  lateral  ligament,  internally  with  the  capsular 
ligament,  whilst  a  portion  of  the  tendon  of  the  external 
pterygoid  muscle  is  inserted  into  it  in  front  control- 
ling its  movements  The  ligaments  are  the  external 
lateral,  attached  to  the  tubercle  on  the  zygoma  and  to 
the  external  surface  of  its  neck,  which  is  covered  over 
by  the  parotid  gland;  and  the  internal  lateral,  attached 
to  the  spine  of  the  sphenoid  and  to  the  inner  margin  of 
the  dental  foramen.  The  external  pterygoid  muscle  is  in 
relation  with  this  ligament  above,  the  internal  maxillary 
artery  lies  between  it  and  the  neck  of  the  jawbone,  and 


60  SURGICAL    ANATOMY    OF 

between  it  and  the  ramus  of  the  jaw  are  the  inferior 
dental  vessels  and  nerve;  and  on  its  inner  side  is  the  in- 
ternal pterygoid  muscle.  The  stylo-maxillary  ligament, 
really  a  slip  of  the  deep  cervical  fascia,  is  attached  to 
the  styloid  process  of  the  temporal  bone  and  to  the  in- 
ferior angle  of  the  lower  jaw,  it  separates  the  parotid 
from  the  submaxillary  gland,  and  gives  origin  to  some 
fibres  of  the  stylo-glossus  muscle. 

Owing  to  the  numerous  movements  which  the  mus- 
cles of  mastication  are  capable  of  causing,  and  to  the 
comparative  laxity  of  the  ligaments  of  the  articulation, 
the  lower  jawbone  is  liable  to  partial  or  complete  dislo- 
cation. The  condyles  glide  forward,  carrying  the  inter- 
articular  nbro-cartilages  with  them,  upon  the  eminently 
articulares,  in  such  conditions  as  yawning  or  laughing, 
or  masticating  large  morsels ;  the  combined  action  of  the 
masseter  and  internal  pterygoid  muscles  drags  them 
under  the  zygomatic  arches,  whilst  the  temporal  muscles 
drag  the  displaced  bone  upwards.  The  obstacle  to  re- 
duction appears  to  be,  that  in  most  cases  the  coronoid 
process  is,  as  it  were,  locked  in  front  of  the  malar  tuber- 
cle. Partial  luxation  of  one  condyle  is  of  common  oc- 
currence, and  occasionally  a  portion  of  that  process  of 
the  parotid  which  wraps  round  the  neck  of  the  jaw  is 
included  between  the  opposing  surfaces,  causing  severe 
pain  and  inconvenience.  The  principle  upon  which  re- 
duction is  effected  is  by  introducing  some  solid  body 
between  the  molar  teeth  so  as  to  form  a  fulcrum,  whilst 
the  power  is  applied  at  the  symphysis,  at  the  same  time 
that  the  angles  are  depressed. 


THE    LINGUAL    REG-ION.  61 

SURGICAL  ANATOMY  OF  THE  LINGUAL  REGION".    - 

The  tongue  completely  occupies  tKe^-ea,vity  of  the 
mouth  when  it  is  shut,  and  is  attached  for  the  posterior 
two-thirds  of  its  volume  to  the  hyoid  bone  and  inferior 
maxillary  bone,  by  its  extrinsic  muscles  and  membranes ; 
by  means  of  the  stylo-glossus  it  is  attached  to  the  styloid 
process,  and  by  the  palato-glossus  to  the  palatine  arch. 
It  is  at  this  portion  of  the  organ  that  the  nerves  and 
arteries  enter  and  its  veins  leave  it.  Beneath  it,  in  the 
middle  line,  is  a  fold  of  mucous  membrane,  the  frsenum, 
on  either  side  of  which  are  the  orifices  of  Wharton's 
ducts,  and  those  of  the  sublingual  glands,  or  ducts  of 
Riviniani,  lie  in  the  fossa  between  the  tongue  and  max- 
illary bone. 

Structure. — The  mucous  membrane  is  very  adherent  to 
the  underlying  structure,  particularly  on  the  dorsurn 
and  sides ;  on  the  under  surface,  however,  it  is  less  so, 
there  being  a  cellular  layer  between  it  and  the  sublingual 
muscles.  The  mucous  membrane  is  freely  supplied  with 
papillae ;  the  sides  and  tip  with  fungiform,  almost  its 
entire  surface  with  filiform,  and  the  posterior  part  of  its 
dorsum  with  the  Y-shaped  series  of  the  circumvallate. 
There  are  a  considerable  number  of  glands  lying  in  this 
tissue,  which  give  rise  to  the  development  of  that  en- 
cysted tumor  known  as  ranula.  An  enlargement  of  the 
bursa  existing  between  the  hyoid  attachment  of  the 
genio-hyoglossi,  by  its  enlargement  and  protrusion  be- 
neath the  tongue,  may  be  mistaken  for  ranula. 

The  muscles  are  both  intrinsic  and  extrinsic.  The 
intrinsic  or  linguales  are  two  symmetrical  bundles  of 
muscular  fibre,  separated  from  each  other  by  a  fibrous 
septum,  occasionally  cartilaginous,  and  these  muscular 


62  SURGICAL    ANATOMY    OF 

fibres  are  arranged  into — (1)  the  Hngualis  superior,  the 
fibres  of  which  are  disposed  obliquely  and  longitudinally 
on  the  surface  of  the  organ ;  (2)  an  inferior  longitudinal 


FIG.  12. 


Lingual  artery  and  its  branches.  1.  Stylo-glossus.  2.  Ranine  artery.  3.  Dor- 
salis  linguae  artery.  4.  Genio-hyoglossus  muscle.  5.  Middle  constrictor.  6. 
Genio-hyoid  muscle.  7,  7.  Hyoglossus  (cut).  8.  Sublingual  gland.  9.  External 
carotid.  11.  Lingual  artery.  12.  Hyoid  branch.  (HEATH.) 

set,  passing  from  the  hyoid  bone  to  the  apex,  and  in  re- 
lation on  its  under  surface  with  the  ranine  artery ;  its 
fibres  are  blended  with  those  of  the  stylo-glossus ;  (3) 
a  transverse  set,  forming  the  bulk  of  the  tongue,  placed 
between  the  superficial  and  longitudinal,  are  attached  to 
the  fibrous  septum,  and  curving  outwards  are  inserted 
into  the  dorsum  linguae  and  its  margin.  The  fibres  in- 
terlace with  the  before-named  sets.  The  existence  of  the 
fibrous  septum  explains  how  it  is  that  in  acute  inflam- 
mation of  the  tongue,  or  when  abscess  has  formed,  the 
tumor  is  frequently  unilateral. 

The  extrinsic  muscles  are, — the  hyo-glossus,  genio- 
hyo-glossus,  stylo-glossus,  palato-glossus,  and  some  few 
fibres  of  the  superior  constrictor. 

Arteries. — The  lingual  artery  at  the  anterior  edge  of 


THE    LINGUAL    REGION.  63 

the  hyo-glossi  muscles  divides  into  the  sublingual  and 
ranine  :  of  these  the  ranine  is  the  most  important;  it  lies 
on  the  under  surface  of  the  tongue,  external  to  the  genio- 
hyo-glossi,  and  on  the  inner  side  of  the  hyo-glossi,  stylo- 
glossi,  and  sublingual  gland.  It  enters  the  organ  at  its 
base,  and  runs  forwards  towards  the  tip,  and  in  the 
mouth  it  lies  to  the  side  of  the  frsenum,  and  is  here  cov- 
ered only  by  mucous  membrane  ;  thus,  in  dividing  this 
membrane  for  tongue-tie,  the  scissors  should  be  directed 
downwards  and  backwards. 

The  ranine  artery  is  generally  accompanied  by  two 
ranine  veins,  which  terminate  in  the  internal  and  exter- 
nal jugular  and  the  facial  veins  (vide  Lingual  Artery). 

The  nerves  are  very  numerous,  and  are  derived  from — 
(1)  the  hypo-glossal  or  ninth,  which  is  supplied  to  the 
extrinsic  muscles  only — it  is  the  motor  nerve  of  the 
tongue ;  (2)  the  gustatory  branch  of  the  inferior  maxil- 
lary division  of  the  fifth,  supplies  the  sides  and  tip — a 
nerve  of  special  sense :  these  two  nerves  freely  inosculate ; 

(3)  the  glosso-pharyngeal,  which  supplies  the  circumval- 
late  papillae  at  its  base — also  a  nerve  of  special  sensation ; 

(4)  the  facial,  supplying  the  linguales,  by  means  of  the 
chorda  tympani ;  (5)  the  vagus,  sending  a  few  filaments 
to  its  base ;  and  (6)   the  sympathetic — the  vaso-motor 
nerve,  accompanying  the  lingual  artery. 

The  base  of  the  tongue  is  in  relation  with  the  epiglot- 
tis, which  curves  forwards  towards  it  during  respiration  ; 
but  during  deglutition  it  is  drawn  backwards  and  down- 
wards, thus  covering  the  aperture  of  the  larynx  and 
preventing  food  from  passing  into  it  (vide  Larynx). 

The  tumors  met  with  beneath  the  tongue  are — ranula, 
salivary  concretions,  fatty,  and  bursal. 


64  SURGICAL    ANATOMY    OF 


SURGICAL  ANATOMY  OF  THE  PHARYNX. 

The  pharynx  presents  for  examination  four  walls, — an 
anterior,  a  posterior,  and  two  lateral. 

The  anterior,  very  oblique  behind  and  below,  contains 
from  above  downwards,  the  posterior  nares,  the  velum 
pendulum  palati,  the  posterior  pillars  of  the  fauces,  base 
of  tongue,  epiglottis,  the  glosso-epiglottic  folds,  and 
larynx. 

The  posterior  wall  is  in  relation  with  the  cervical  ver- 
tebrae, being  separated  from  them  by  the  recti  antici  and 
longi  colli  muscles.  Between  the  muscular  coat  of  the 
pharynx,  which  is  formed  by  the  constrictors,  is  a  quan- 
tity of  loose  cellular  tissue,  in  which  retro-pharyngeal 
abscesses  form,  frequently  from  disease  of  the  cervical 
vertebrae.  These  abscesses  push  the  pharynx  forward 
against  the  posterior  nares  if  high  up,  and  if  lower  down, 
by  pressing  upon  the  larynx  interfere  with  respiration 
and  speech.  Occasionally  these  abscesses  point  at  the 
side  of  the  neck  in  front  of  the  sterno-cleido-mastoid  (vide 
Fasciae  of  Neck). 

The  lateral  walls,  also  formed  by  the  constrictors,  are 
in  relation  with  the  sympathetic,  glosso-pharyngeal, 
spinal  accessory,  vagus,  hypo-glossal  nerves,  internal 
carotid  artery,  and  internal  jugular  vein.  In  front  of 
the  vessels  and  nerves,  the  pterygo-maxillary  region, 
pterygoid  plates  of  the  sphenoid,  deep  portion  of  the 
parotid,  and  the  lateral  portion  of  the  submaxillary 
region  are  in  immediate  relation  with  them.  This  close 
relation  to  the  parotid  and  internal  maxillary  regions, 
explains  the  pointing  of  abscesses  forming  in  these  spaces 
at  the  sides  of  the  pharynx. 

It  is  hardly  necessary  to  remind  the  student  that  in 


THE    PHARYNX.  65 

passing  a  bougie,  stomach-pump  tube,  or  probang,  care 
must  be  taken  to  apply  it  firmly  to  the  posterior  wall  of 
the  pharynx  to  avoid  entering  the  trachea.  In  making 
an  examination  of  the  pharynx  for  the  detection  and  re- 
moval of  foreign  bodies,  it  will  be  noticed  that  far  more 
of  its  cavity  can  be  reached  with  the  finger  than  might 
be  supposed,  and  instruments  must  be  used  very  care- 
fully and  sparingly  in  searching  for  them ;  moreover,  it 
must  be  remembered  that  the  walls  of  the  pharynx  are 
in  close  contact  when  not  transmitting  food. 


66  SURGICAL    ANATOMY    OF    THE    NECK. 


CHAPTER  II. 

SUKGICAL  ANATOMY  OF  THE  NECK. 

THE  region  of  the  neck  is  that  portion  of  the  body 
which  is  contained  between  the  occipital  bone  above, 
and  the  superior  aperture  of  the  thorax  below — namely, 
the  first  t\vo  ribs,  laterally ;  the  manubrium  sterni,  ante- 
riorly ;  and  the  first  dorsal  vertebra,  posteriorly ;  and 
for  the  sake  of  simplicity  will  be  divided  as  follows : 

An  anterior,  including  the  submaxillary  or  supra- 
hyoid  region ;  a  lateral,  the  sterno-mastoid  or  carotid, 
the  supra-clavicular,  the  occipital ;  and  a  posterior,  in- 
cluding the  nape  of  the  neck, — a  method  which  seems 
advisable  as  being  a  natural  one,  and  agreeable  to  its  ex- 
ternal conformation. 

Surface  Markings. — The  development  of  the  neck 
varies  in  individuals,  both  with  regard  to  age  and  to 
sex :  round  and  smooth  in  females  and  children  ;  mus- 
cular, and  with  all  its  prominences  well  marked,  in 
adult  males. 

As  far  as  its  normal  length  is  concerned,  in  adults  it 
is  tolerably  constant,  the  difference  in  certain  persons 
being  rather  apparent  than  real,  resulting  from  some 
peculiarity  in  the  conformation  of  the  shoulders,  &c. 
Its  breadth  is  variable. 

In  the  natural  position,  that  is,  when  the  base  of  the 
skull  is  parallel  to  the  ground,  the  markings  of  chief  in- 


SURGICAL    ANATOMY    OF    THE    NECK.  67 

terest  to  the  surgeon  are  those  of  the  hyoid  and  laryn- 
geal  apparatus  and  the  sterno-mastoids,  and  the  hollows 
between  and  behind  these  muscles.  The  first  prominence 
below  the  chin  is  the  pomum  Adami,  which  is  far  more 
prominent  in  males  than  in  females,  and  becomes  devel- 
oped at  puberty ;  nearly  a  finger's  breadth  above  this 
can  be  felt  the  hyoid  bone,  with  the  anterior  belly  of  the 
digastric  muscle  sweeping  upward  towards  the  chin. 
Immediately  below  the  thyroid  cartilages,  in  the  median 
line,  is  a  depression,  indicating  the  position  of  the  crico- 
thyroid  membrane ;  next,  the  body  of  the  cricoid  carti- 
lage itself;  below  this,  the  upper  rings  of  the  trachea 
may  be  distinguished,  and  at  about  the  third  ring  the 
isthmus  of  the  thyroid  body  can  generally  be  made  out, 
more  particularly  in  women.  The  position  of  the  laryn- 
geal  apparatus  during  swallowing  should  be  noticed,  as 
it  is  drawn  upwards  at  the  commencement  of  the  act, 
returning  to  its  normal  position  on  its  completion,  the 
thyroid  body  being  carried  with  it.  This  fact  is  of  great 
value  in  the  diagnosis  of  tumors  in  the  region  of  the 
trachea  or  carotid  vessels.  In  children  the  trachea  is 
more  deeply  placed,  very  small,  and  movable  (vide 
Trachea). 

The  anterior  and  posterior  borders  of  the  sterno-cleido- 
mastoidei  are  very  evident,  even  when  these  muscles  are 
at  rest,  from  the  prominent  mastoid  processes  to  their 
inferior  attachments — the  sternal  of  which  is  fusiform 
and  cordlike,  and  the  clavicular,  flat  and  ribbon-shaped, 
lying  posterior  to  the  former,  aud  variable  in  its  extent 
along  the  clavicle.  The  point  of  divergence  of  these 
two  sets  of  fibres  is  generally  well  seen,  more  especially, 
however,  when  the  muscle  is  in  action,  as  in  rotation  of 
the  head  from  side  to  side.  These  points  will  be  here- 


68  SURGICAL    ANATOMY    OF    THE    NECK. 

after  seen  to  be  important  landmarks  to  the  surgeon  in 
the  operative  surgery  of  the  neck.  Between  the  angle 
of  the  jaw  and  the  mesial  line  is  the  protrusion  of  the 
submaxillary  gland,  the  difference  in  the  position  of 
which  during  flexion  or  extension  of  the  neck,  should  be 
carefully  noted.  Above  the  clavicle,  and  between  the 
prominences  of  the  sterno-mastoid  and  trapezius,  is  a 
hollow,  the  subclavian,  or  supra-clavicular  fossa,  at  the 
lower  and  internal  part  of  which  the  posterior  belly  of 
the  omo-hyoid  crops  up  from  behind  the  clavicle.  This 
muscle  lies  much  more  hidden  by  the  sterno-cleido-mas- 
toid  and  clavicle  than  usually  represented  in  plates  of 
the  posterior  triangle.  It  is  seen  in  action  after  swal- 
lowing, during  the  depression  of  the  hyoid  bone,  and 
during  deep  inspiration.  The  subclavian  artery  beats 
at  the  bottom  of  this  hollow,  and  is  here  readily  com- 
pressed against  the  first  rib  (vide  Surgical  Anatomy  of 
Subclavian  Triangle).  The  lateral  contour  of  the  neck 
is  completed,  behind,  by  the  sweep  of  the  trapezius  from 
the  occiput  to  the  tip  of  the  shoulder.  Posteriorly  the 
neck  presents  a  median  depression,  on  either  side  of 
which  is  seen  the  mass  of  the  extensor  muscles  of  the 
head,  and  lower  down  the  spinous  processes  of  the  seventh 
and  eighth  cervical  vertebrae.  A  collection  of  lymphatic 
ganglia  is  usually  very  apparent  in  this  region.  The 
external  jugular  veins  are  seen  on  the  lateral  aspect  of 
the  neck,  crossing  the  sterno-mastoid  obliquely,  from 
before  backwards,  at  about  its  middle,  and  passing  into 
the  hollow  behind  it.  The  more  detailed  account  of 
these  superficial  markings  is  attached  to  the  description 
of  the  several  regions  of  the  neck. 

Arrangement  of  the  Cervical  Fascia.  —  The   attach- 
ments and  connection  of  the  fasciae  of  the  neck  are  of 


SURGICAL    ANATOMY    OF    THE    NECK.  69 

great  surgical  importance,  inasmuch  as  these  aponeurotic 
sheaths  in  a  great  measure  control  the  course  taken  by 
diffuse  inflammation,  collections  of  pus,  blood,  and 
growths ;  the  latter  frequently  not  appearing  externally 
in  the  neck  until  some  while  after  they  have  extended 
or  sent  processes  along  or  amongst  them. 

For  convenience  of  examination  and  simplicity  of 
description  it  may  be  divided  into  two  layers, — a  super- 
ficial, and  a  deep.  The  superficial  layer  is  usually  traced 
from  behind,  where  it  commences  as  a  very  thin  lamina 
attached  to  the  spinous  processes  of  the  cervical  verte- 
brae, superior  curved  line  of  the  occipital  bone,  and  lig- 
amentum  nuchae ;  and  passing  forwards,  getting  denser 
as  it  proceeds,  it  incloses  the  trapezius,  and,  forming 
sheaths  for  the  posterior  muscles  of  the  neck,  extends 
over  the  posterior  triangular  space,  and  arriving  at  the 
posterior  border  of  the  sterno-cleido-mastoid,  forms  a 
sheath  for  it ;  and  part  of  it,  which  constitutes  the  an- 
terior portion  of  this  sheath,  is  attached  to  the  lower 
border  of  the  body  and  angle  of  the  lower  jaw  and 
zygoma,  after  having  covered  in  anteriorly  the  parotid 
gland  and  masseter  muscle ;  below  it  is  attached  to  the 
anterior  part  of  the  clavicle  "and  manubrium  sterni,  and 
is  perforated  by  the  external  jugular  vein  and  cutaneous 
nerves.  The  deeper  layer  has  an  attachment  to  the 
tubercles  of  the  transverse  processes  of  the  cervical  ver- 
tebrae, and  incloses  the  scaleni  muscles,  forming  the 
prevertebral  aponeurosis,  which  sends  processes  over  the 
cords  of  the  cervical  and  brachial  plexuses  and  sub- 
clavian  vessels.  The  lax  cellular  tissue  lying  between 
the  prevertebral  aponeurosis  and  the  pharyngeal  muscles 
is  the  seat  of  retro-pharyngeal  abscesses,  which  point 
either  into  the  pharynx  or,  guided  by  fascia,  behind  the 


70  SURGICAL    ANATOMY    OF    THE    NECK. 

carotid  vessels  (vide  Pharynx).  Passing  from  the  under 
surface  of  the  sterno-mastoid  towards  the  middle  line, 
it  is  attached  to  the  hyoid  bone,  forming  an  aponeurotic 
loop  on  its  upper  surface,  through  which  runs  the  tendon 
of  the  digastric ;  and  extending  downwards  it  forms  the 
sheaths  of  the  sterno-hyoid  and  sterno-thyroid  muscles. 
The  lamina  forming  the  posterior  portion  of  the  sheath 
of  the  sterno-mastoid  is  attached  above  to  the  angle  of 
the  jaw  and  to  the  base  of  the  styloid  process  behind, 
and  to  the  inner  side  of  the  parotid  gland,  forming  a 
septum  between  it  and  the  submaxillary  gland,  the  stylo- 
maxillary  ligament.  The  lower  portion  of  this  lamina 
forms  the  sheath  of  the  carotid  vessels,  which  sheath  is 
divided  by  septa  inclosing  internally  the  carotid  artery, 
externally  the  internal  jugular  vein,  and  posteriorly  the 
vagus  nerve;  traced  downwards  and  outwards  it  is  found 
to  inclose  the  omo-hyoid  muscle,  binding  it  down  to  the 
clavicle,  and  inclosing  the  subclavius  muscle,  passes 
beneath  it  into  the  axilla,  to  be  continuous  with  its 
fasciae  (vide  Axilla).  At  the  root  of  the  neck  this  fascia 
is  easily  demonstrated  to  be  continuous  with  the  peri- 
cardium. 

That  portion  of  the  fascia  which  is  attached  to  the 
hyoid  bone  above,  and  to  the  clavicle  and  sternum  be- 
low, has  been  supposed  to  have  some  influence  on  respi- 
ration, inclosing  in  its  reflexions  the  depressors  of  the 
hyoid  bone,  and  sending  processes  around  the  great 
venous  trunks.  The  omo-hyoidei  in  particular  by  their 
contraction  tighten  it,  and  being  made  tense,  the  calibre 
of  the  veins  is  increased,  and  as  these  muscles  only  con- 
tract during  inspiration,  the  dilatation  of  the  veins  coin- 
cides with  the  dilatation  of  the  thorax,  thereby  urging 
the  blood  towards  the  heart.  This,  moreover,  explains 


SURGICAL  ANATOMY  QF  SUBMAXILLARY  REGION.     71 


readily  air  may  pass  into  the  right  "side  of  the 
heart,  should  any  one  of  the  larger  veins,  -or  some 
branch  close  to  the  trunk,  be  divided. 

These  several  layers  of  fascia  are  attached  both  to  the 
margins  of  the  superior  aperture  of  the  thorax  and  to 
those  structures  which  pass  upwards  or  downwards 
through  it;  and  as  they  are  connected  together  by  trans- 
verse septa,  they  constitute  a  species  of  diaphragm  be- 
tween the  cervical  and  thoracic  regions. 


SUKGICAL  ANATOMY  OF  THE  STJBMAXILLAKY 
REGION. 

This  region  is  bounded  above  by  the  body  of  the 
lower  jaw,  and  the  floor  of  the  mouth ;  below,  by  the 
hyoid  bone;  externally,  by  the  anterior  margin  of  the 
sterno-cleido-mastoid  muscle.  Its  surface-markings  have 
been  already  described  (vide  Neck). 

Dissection. — On  reflecting  the  integument,  immedi- 
ately beneath  it,  is  the  subcutaneous  cellular  tissue,  and 
the  fibres  of  the  platysma  myoides  muscle  passing  ob- 
liquely from  the  jaw  towards  the  chest  and  shoulder, 
the  a'nterior  border  of  which  is  free,  and  separated  from 
its  fellow  by  a  cellular  interval.  Beneath  this  muscle  is 
a  very  lax  cellular  tissue,  and  on  turning  it  up  along 
the  body  of  the  jaw,  are  seen  the  nerves  supplying  it, 
derived  from  the  facial  and  upper  cervical.  A  portion 
of  the  superior  layer  of  the  deep  cervical  fascia  is  next 
met  with,  attached  along  the  jaw  covering  in  the  sub- 
maxillary  gland,  and  forming  the  anterior  portion  of  its 
capsule ;  it  is  continuous  externally  with  the  sheath  of 
the  sterno-cleido-mastoid,  and  with  the  fascia  covering 
the  parotid  anteriorly.  A  great  many  lymphatics  lie 


72  SURGICAL    ANATOMY    OF 

either  upon  or  beneath  the  capsule  of  this  gland,  and 
can  be  readily  felt  beneath  the  integument.  Beneath 
this  aponeurosis,  and  inclosed  by  that  portion  of  it 
which  is  attached  to  the  cornu  of  the  hyoid  bone,  are 
the  submaxillary  gland,  the  stylo-hyoid  and  digastric 
muscles.  The  fibres  of  the  stylo-hyoid  are  seen  inclos- 
ing the  tendon  of  the  digastric  and  inserted  into  the 
hyoid  bone,  just  before  that  muscle  passes  through  the 
loop  derived  from  the  deep  cervical  fascia.  The  mus- 
cular fibres  of  the  posterior  belly  of  the  digastric  are 
superior  to  those  of  the  stylo-hyoid,  and  after  being  re- 
flected from  the  hyoid  bone,  spread  out  into  a  large 
muscular  mass,  having  many  tendinous  intersections 
(frequently  interlacing  with  the  opposite  muscle),  to  be 
inserted  into  the  digastric  fossa  of  the  inferior  maxilla. 
Lying  in  the  interval  between  the  two  bellies  of  the 
digastric,  and  overlapped  by  its  posterior  belly,  and  by 
the  body  of  the  jaw,  is  the  submaxillary  gland,  inclosed 
in  its  capsule,  the  posterior  portion  of  which  is  continu- 
ous with  the  stylo-maxillary  ligament,  which  separates 
it  from  the  parotid  gland,  and  superior  to  it  is  the  facial 
artery  and  vein ;  the  submental  branches  of  these  vessels, 
with  the  nerve  to  the  anterior  belly  of  the  digastric,  pass 
forwards  towards  the  symphysis  under  cover  of  the  body 
of  the  jaw.  The  bulk  of  the  gland  being  pulled  up- 
wards from  the  fossa  in  which  it  is  lodged,  it  will  be 
observed  that  a  portion  of  it  passes  beneath  the  mylo- 
hyoid  muscle,  upon  which  the  greater  part  of  it  rests. 

Parts  beneath  the  Mylo-hyoid. — The  mylo-hyoid  mus- 
cle should  now  be  divided  and  reflected,  when  from 
before  backwards  will  be  seen  the  genio-hyoid  anteriorly, 
and  deeper  down  the  genio-hyo-glossus,  along  the  outer 
side  of  which  lie  the  ranine  vessels,  and  external  to  it 


THE    SUBMAXILLARY    REGION.  73 

the  deep  portion  of  the  subm axillary  and  the  sublingual 
glands,  and  the  mucous  lining  of  the  floor  of  the  mouth ; 
posteriorly,  the  hyo-glossus  muscle,  extending  from  the 
cornu  of  the  hyoid  bone  to  the  side  of  the  tongue,  and 
upon  this  muscle  from  below  upwards  lie — (1)  the  ninth 
or  hypoglossal  nerve;  (2)  Wharton's  duct;  (3)  the  gus- 
tatory nerve  with  the  submaxillary  ganglion  and  chorda 
tympani,  and  the  inosculating  branches  of  these  two 
nerves.  Upon  the  cornu  of  the  hyoid  bone  is  seen  the 
trunk  of  the  lingual  artery  just  before  it  disappears 
behind  the  hyo-glossus  muscle. 

Arteries. — The  facial  artery  in  this  region  passes 
beneath  the  posterior  belly  of  the  digastric  and  stylo- 
hyoid  and  submaxillary  gland,  and  after  giving  off 
branches  to  the  gland,  and  the  submental,  it  becomes 
subcutaneous,  about  an  inch  in  front  of  the  angle  of  the 
jaw. 

The  lingual  artery  is  deeper  in  its  course  and  distribu- 
tion, and  is  directed  towards  the  hyo-glossus,  and  is  at 
first  covered  by  the  skin,  platysrna,  and  fascia,  and  rests 
on  the  middle  constrictor ;  after  passing  over  the  cornu 
of  the  hyoid  bone,  it  is  crossed  by  the  ninth  nerve,  the 
digastric  and  stylo-hyoid  muscles  forming  an  arch  over 
it.  It  is  next  covered  by  the  hyo-glossus,  and  lies  on 
the  superior  constrictor  and  genio-hyo-glossus  muscles. 

The  branches  given  off  from  it  are, — the  hyoid,  which 
runs  along  the  upper  border  of  the  hyoid  bone;  the 
dorsalis  linguae,  supplying  the  dorsum  of  the  tongue, 
tonsil,  and  soft  palate ;  the  sublingual,  supplying  its  sub- 
stance, and  the  ranine. 

Ligature  of  Lingual  Artery. — To  place  a  ligature  upon 
the  lingual  artery,  that  portion  of  its  coarse  where  it  lies 
upon  the  great  cornu  of  the  hyoid  bone  is  selected,  im- 


74  SURGICAL    ANATOMY    OF 

mediately  before  it  passes  behind  the  outer  border  of  the 
hyo-glossus  muscle,  as  it  is  there  most  accessible ;  and  to 
reach  it,  an  incision  is  to  be  made  about  a  finger's  breadth 
below  the  body  of  the  jaw  through  the  integument  and 
aponeurosis,  and  the  gland  is  to  be  lifted  upwards.  After 
the  posterior  portion  of  the  capsule  of  the  gland  has  been 
divided,  the  combined  lingual  and  facial  veins  are  seen 
passing  obliquely  backwards,  and  deeper,  the  hypo- 
glossal  nerve ;  at  the  angle  where  this  nerve  meets  the 
tendon  of  the  digastric,  lies  the  artery,  taking  a  curve 
downwards  towards  the  hyoid  bone.  Occasionally  the 
vessel  pierces  the  hyo-glossus  muscle,  or  this  muscle  ex- 
tends farther  back  than  usual,  in  which  case  its  fibres 
must  be  divided.  On  the  dead  body  the  vessel  appears 
to  be  tolerably  near  the  surface,  but  during  life  the  fascia 
and  integuments  are  so  on  the  stretch  and  so  attached 
to  the  salient  parts  of  the  region,  that  when  the  vessel 
is  exposed,  it  is  actually  very  deep.  The  operation  is  a 
difficult  one,  the  vessel  being  only  supported  by  the  loose 
wall  of  the  pharynx,  which  runs  considerable  danger  of 
being  wounded,  so  that  the  only  sure  firm  guide  to  it  is 
the  posterior  cornu  of  the  hyoid  bone.  The  hyoid  bone 
may  be  with  advantage  drawn  forwards  into  the  wound 
and  steadied  with  a  hook  (vide  Eegion  of  Tongue). 

Veins. — There  is  often  a  considerable  plexus  of  veins 
in  this  region,  the  most  important  being  the  facial  and 
the  lingual ;  the  facial  leaves  its  artery  and  passes  upon 
the  fascia  in  front  of  the  submaxillary  gland,  whilst 
the  lingual  vein  is  separated  from  its  artery  by  the  hyo- 
glossus  muscle.  Very  often  these  veins  form  a  common 
trunk,  lying  superficial  to  the  hypoglossal  nerve,  before 
entering  the  jugular  vein. 

Nerves. — The  superficial  nerves   have  been  already 


THE    INFRA-HYOID    REGION.  75 

referred  to;  the  hypoglossal  enters  the  region  superficial 
to  the  external  carotid  and  below  the  stylo-hyoid  and 
digastric  muscles,  and  passes  upwards  over  the  cornu  of 
the  hyoid  bone  between  the  glands  and  the  hyo-glossus 
muscles,  covered  in  by  the  mylo-hyoid ;  it  loops  with  the 
gustatory  and  is  seen  distributed  to  the  extrinsic  muscles 
of  the  tongue.  The  gustatory  nerve,  with  the  chorda 
tympani,  lies  beneath  the  gland  and  passes  to  the  mucous 
membrane  of  the  sides  and  tip  of  the  tongue,  upon  its 
deeper  portion. 

The  above  relations  are  those  borne  by  the  different 
structures  in  this  region,  when  the  head  is  in  its  natural 
position,  but  when  the  parts  are  the  seat  of  operation, 
the  head  is  thrown  back  and  the  contents  of  the  space 
put  on  the  stretch ;  by  so  doing  the  position  of  the  sub- 
maxillary  gland  and  the  facial  vessels  are  considerably 
altered  by  the  cavity  which  naturally  exists  between  the 
lower  jaw  and  the  mylo-hyoid  muscle  becoming  flattened, 
thereby  causing  a  protrusion  of  the  structures  between 
them. 

SURGICAL  ANATOMY  OF  THE  INFRA-HYOID 
REGION. 

The  boundaries  of  this  region  are, — above,  the  hyoid 
bone  and  the  base  of  the  tongue ;  laterally,  the  sterno- 
mastoid  muscles  (and  carotid  vessels) ;  and  below,  the 
upper  border  of  the  manubrium  sterni,  or  interclavicu- 
lar  notch  ;  posteriorly,  the  cervical  vertebrse,  covered  by 
the  longi  colli  muscles.  This  region  is  surgically  im- 
portant as  containing  the  larynx  and  trachea,  the  cervi- 
cal portion  of  oasophagus,  and  the  thyroid  body,  with 
their  respective  vessels  and  nerves.  Its  surface  mark- 
ings have  been  already  described  (vide  Neck). 


76  SURGICAL    ANATOMY    OF 

Dissection. — On  the  removal  of  the  integument,  the 
subcutaneous  cellular  tissue  is  first  met  with,  and  the 
anterior  portion  of  the  platysma,  which  is  usually  un- 
connected with  its  fellow  of  the  opposite  side,  there 
being  a  cellular  interval  between  them,  well  marked  in 
the  necks  of  old  people  when  the  fat  is  absorbed,  caus- 
ing the  "  dewlap "  appearance  characteristic  of  age. 
Beneath  these  muscular  fibres  is  a  thin  layer  of  cellular 
tissue,  which  allows  of  the  free  movements  of  the  in- 
tegument and  platysma  over  the  underlying  aponeurotic 
sheaths  of  the  muscles.  Along  the  anterior  border  of 
the  sterno-mastoid  is  the  anterior  jugular  vein,  which, 
however,  is  at  times  absent.  The  sterno-hyoid  and 
omo-hyoid  muscles  themselves  form  the  next  layer,  in 
their  aponeurotic  sheaths,  and  immediately  below  them 
lie  the  sterno-thyroid  and  thyro-hyoid  muscles.  The 
sterno-hyoid  muscles  pass  somewhat  obliquely,  so  that 
the  interspace  between  their  internal  free  borders  is 
rather  wider  towards  the  sternum  than  at  the  hyoid 
bone ;  whilst  the  inner  margins  of  the  sterno-thyroids 
are  slightly  oblique  in  the  opposite  direction. 

The  nerves  supplying  these  muscles  are  seen  gener- 
ally on  their  posterior  borders,  or  ramifying  upon  them. 
Beneath  the  muscles  just  named,  in  the  mesial  line, 
from  above  downwards,  are  met  with — (1)  the  hyoid 
bone;  (2)  the  thyro-hyoid  membrane;  (3)  the  thyroid 
cartilage ;  (4)  the  crico-thyroid  membrane ;  (5)  the  cri- 
coid  cartilage,  partly  covered  by  the  crico-thyroid  mus- 
cle ;  (6)  the  first  ring  or  two  of  the  trachea ;  (7)  the  thy- 
roid body  and  its  isthmus  extending  between  the  lobes ; 
(8)  the  trachea  (passing  backwards  and  downwards  to- 
wards the  thorax),  upon  which  lies  a  plexus  of  veins, 
the  inferior  and  middle  thyroid,  passing  downwards 


THE    INFRA  -HYOID    REGION.  77 

from  the  thyroid  body ;  and  the  thyroidea  iraa  artery, 
when  it  exists,  is  generally  a  branch  of  the  innominata. 
On  the  right  side  of  the  neck,  the  common  carotid 
artery  crosses  the  lower  portion  of  the  trachea  obliquely, 
but  subsequently  lies  parallel  to  it ;  on  the  left  side  the 
common  carotid  is  deeper  than  on  the  right  and  lies 
along  the  trachea.  It  must  be  borne  in  mind  that 
neither  of  these  vessels  is  in  actual  contact  with  the 
trachea.  Behind  the  trachea  is  the  oesophagus,  which 
commences  opposite  the  fifth  cervical  vertebra  and  cri- 
coid  cartilage,  and  passes  to  its  left  side — a  circumstance 
which  is  taken  advantage  of  for  the  performance  of  the 
operation  of  oesophagotomy.  On  either  side  is  the  com- 
mon carotid  artery,  the  nearer  being  the  left,  owing  to 
the  projection  of  the  oesophagus  towards  that  side ;  and 
crossing  it  obliquely  are  the  superior  and  inferior  thy- 
roid arteries.  The  recurrent  laryngeal  nerve  lies  in  the 
interspace  between  the  borders  of  the  trachea  and  oesoph- 
agus, and  passes  below  the  inferior  constrictor  and  into 
the  larynx  through  the  crico-thyroid  membrane.  The 
oesophagus  is  separated  from  the  cervical  spine  and  the 
muscles  covering  it — viz.,  the  recti  antici,  longi  colli, 
and  that  portion  of  the  deep  cervical  fascia  which  is 
applied  to  their  anterior  surface,  by  a  layer  of  very  lax 
cellular  tissue,  which  permits  of  the  constant  gliding  of 
the  oesophagus  and  trachea  in  their  several  movements, 
and  is,  as  before  mentioned,  frequently  the  seat  of  ab- 
scesses. For  greater  convenience  of  reference,  two  tri- 
angular spaces,  termed  by  Velpeau  the  omo-hyoid  and 
the  omo-tracheal,  may  be  noted  ;  the  former,  bounded 
by  the  hyoid  bone  above,  sterno-mastoid  externally, 
and  the  omo-hyoid  internally,  contains  the  superior 
thyroid  artery,  superior  laryngeal  nerve,  a  portion  of 


78  SURGICAL    ANATOMY    OF 

the  middle  and  inferior  constrictors,  alee  of  thyroid  car- 
tilage, and  thyro-hyoid  membrane ;  the  latter  is  bounded 
above  and  externally  by  the  omo-hyoid,  below  and  ex- 
ternally by  the  sterno-mastoid,  and  internally  by  the 
middle  line  of  the  neck,  and  contains  the  sterno-hyoid 
and  thyroid  muscles,  a  lobe  of  the  thyroid  body,  the 
superior  and  inferior  thyroid  arteries,  descendens  and 
communicans  noni  nerves,  sides  of  cricoid  cartilage  and 
trachea,  the  recurrent  laryngeal  nerves,  and,  on  the  left 
side,  the  oesophagus. 

The  superior  thyroid  artery  arises  from  the  external 
carotid  artery,  opposite  the  greater  cornu  of  the  hyoid 
bone,  and  at  first  lies  superficially,  in  a  space  bounded 
by  the  sterno-mastoid,  digastric,  and  omo-hyoid  mus- 
cles. It  then  passes  upwards  and  inwards,  and  arches 
down  to  the  upper  part  of  the  lobe  of  the  thyroid  body, 
lying  below  the  omo-hyoid,  sterno-hyoid,  and  sterno- 
thyroid  muscles,  having  behind  it  the  superior  laryn- 
geal nerve.  Its  crico-thyroid  branch  runs  transversely 
across  the  thyro-hyoid  membrane,  and  may  be  wounded 
in  laryngotomy. 

The  inferior  thyroid  artery,  in  this  region,  passes  ob- 
liquely upwards  and  inwards,  crossing  behind  the  com- 
mon carotid  artery,  internal  jugular  vein,  pneumo- 
gastric,  and  sympathetic  nerves ;  and  on  the  left  side  it 
lies  in  front  of  the  oesophagus  and  behind  the  thoracic 
duct,  and  enters  the  lower  part  of  the  lobe  of  the  thy- 
roid body.  These  vessels  very  freely  anastomose  with 
each  other,  and  with  those  on  the  opposite  side.  The 
superior  laryngeal  nerve  lies  deep  down  in  this  region, 
passing  behind  the  external  and  internal  carotids,  and 
divides  into  two  branches — an  external,  supplied  to  the 
crico-thyroid  muscle,  and  a  deep  one,  penetrating  the 


THE    INFRA-HYOID    REGION.  79 

thyro-hyoid  membrane  and  distributed  to  the  mucous 
membrane  of  the  larynx  (vid&  Subclavian  Artery). 
This  region  is  of  great  surgical  importance ;  as  well  as 
being  the  usual  seat  of  injuries  inflicted  suicidally  or 
homicidally,  the  operations  of  laryngotomy,  cricotomy, 
tracheotomy,  and  oesoph'agotomy  are  performed  therein. 

Non-surgical  wounds,  whether  suicidal  or  otherwise, 
are  invariably  made  across,  and,  as  a  rule,  the  main 
vascular  trunks  escape,  unless  the  attempt  be  very  de- 
termined, for  the  head  is  thrown  back  and  these  main 
trunks  recede,  on  the  structures  beneath  the  sterno- 
mastoid  being  put  on  the  stretch.  The  usual  situation 
selected  for  such  attempts  is  the  thyro-hyoid  space,  and 
the  incisions  frequently  divide  the  larynx  and  some 
branches  of  the  superior  thyroid  artery,  and  not  un- 
frequently  cut  through  the  base  of  the  tongue  and  epi- 
glottis. 

All  openings  made  surgically  into  the  air-passage  are 
made  in  the  middle  line,  for  the  very  important  reason 
that  the  muscular  coverings  of  the  trachea  do  not  unite 
in  the  mesial  line,  but  merely  approximate,  leaving  a 
cellular  interval,  through  which  the  windpipe  is  reached. 
Unless  the  middle  line  be  adhered  to,  although  the  tra- 
chea may  be  opened,  great  difficulty  will  probably  be 
experienced  in  the  introduction  of  the  tube,  as  it  will 
have  a  tendency  to  slide  between  the  muscles  and  the 
trachea,  and  miss  the  opening  made  in  it.  Again,  sup- 
posing no  difficulty  to  arise  of  this  nature,  the  muscle  is 
so  much  wounded  as  to  be  seriously  impaired,  and  may 
become  united  to  the  integument  after  the  tube  is  re- 
moved. 

There  are  three  methods  by  which  the  windpipe  may 
be  opened,  viz. : 


80         SURGICAL  ANATOMY  OF  THE 

Laryngotomy,  in  which  the  crico-thyroid  membrane 
is  divided  ;  this  is  the  readiest  method  of  admitting  air, 
the  only  difficulty  which  might  arise  being  the  hemor- 
rhage from  the  crico-thyroid  arteries,  which  run  across 
this  space.  The  incision  in  the  membrane,  which  is 
made  horizontally,  must  not  be  "so  wide  as  to  injure  the 
crico-thyroid  muscles. 

Tracheotomy  is  the  operation  in  which  the  rings  of  the 
trachea  are  divided  either  above  or  below  the  isthmus  of 
the  thyroid  body.  It  must  be  borne  in  mind  that, 
although  the  trachea  is  very  superficial  above,  it  recedes, 
and  is  very  deep  below,  and,  just  above  the  sternum  is 
generally  at  least  an  inch  from  the  surface,  its  depth 
varying  according  to  the  amount  of  fat  or  muscle  in  the 
individual,  or  to  the  incurvation  of  the  cervical  vertebrae. 
It  is  crossed  at  about  its  second  or  third  rings  by  the 
isthmus  of  the  thyroid  body,  and  below  the  isthmus,  on 
the  lower  part  of  the  trachea,  lie  the  middle  and  inferior 
thyroid  veins,  which  are  generally  greatly  engorged,  on 
account  of  the  asphyxia  necessitating  the  operation. 
Occasionally  the  rings  are  ossified  in  old  persons,  and 
may  cause  trouble. 

In  children,  owing  to  the  shortness  of  the  neck,  and 
the  depth,  small  calibre,  and  mobility  of  the  trachea, 
the  operation  is  a  difficult  one.  Again,  the  plexus  of 
veins  in  connection  with  the  thyroid  body  and  the  close- 
ness of  the  carotids,  render  it  one  demanding  the  greatest 
care.  The  innominate  is  proportionably  higher  up  in 
the  neck  than  in  the  adult,  on  account  of  its  obliquity. 
In  children  under  two  years  of  age,  and  in  some  in- 
stances far  older,  the  thymus  gland  may  give  great 
trouble  by  bulging  up  into  the  wound,  and  so  obstruct- 
ing the  operator's  view  of  the  parts. 


REGION    OF    THE    CAROTID    ARTERIES.  81 

Cricotomy  consists  in  dividing  the  cricoid  cartilage ; 
but  it  is  an  operation  rarely  resorted  to. 

Foreign  bodies  in  the  trachea  are  naturally  directed 
towards  the  right  bronchus,  because  it  is  wider  than  the 
left.  The  septum  at  the  bottom  of  the  trachea,  which 
separates  the  bronchi,  occupies  the  left  of  the  median 
line. 

The  right  bronchus  is  shorter  and  more  horizontal 
than  the  left,  being  about  one  inch  long.  The  left  is 
about  two  inches  in  length,  and  is  directed  more  obliquely 
than  the  right. 

SUKGICAL  ANATOMY  OF  THE  STERNO-MASTOID  RE- 
GION,  OK  REGION  OF  THE  CAROTID  ARTERIES 
ABOVE  THE  STERNO-CLAVICULAR  ARTICULA- 
TION. 

The  boundaries  of  this  region  may  be  sufficiently 
stated  as  being  those  occupied  by  the  sterno-cleido-mas- 
toid  muscle  itself.  This  muscle  forms  an  oblique  rec- 
tangular eminence,  and  is  attached  above  to  the  mastoid 
process  and  the  superior  curved  line  of  the  occipital  bone, 
its  broad  tendinous  insertion  being  blended  with  the 
fibres  of  origin  of  the  trapezius ;  passing  downwards  and 
forwards,  its  muscular  fibres  become  divided,  the  anterior 
set  collecting  themselves  into  a  round  fusiform  bundle, 
to  be  attached  to  the  manubrium  sterni,  and  a  posterior 
bundle,  a  flattened  riband-like  band,  separated  from  the 
former  by  a  cellular  interval,  and  attached  for  a  variable 
distance  along  the  inner  and  upper  aspect  of  the  clavicle. 
(Occasionally  these  clavicular  fibres  pass  along  the  whole 
inner  two-thirds  of  the  clavicle,  forming  a  muscular 
layer,  almost  covering  in  the  posterior  triangular  space.) 
This  interval  in  the  disposition  of  the  muscular  fibres  is 


82         SURGICAL  ANATOMY  OF  THE 

of  great  surgical  importance.  The  anterior  border  is  the 
more  prominent,  and  is  rounder  than  the  posterior,  which 
becomes  lost  in  the  general  surface  of  the  posterior  part 
of  the  neck.  In  most  works  on  descriptive  anatomy  it 
is  not  sufficiently  enforced  that  this  muscle  completely 
covers  in  the  common,  internal,  and  external  carotids, 
and  that  while  the  muscle,  its  integuments,  and  the 
fascial  coverings  are  intact,  it  may  surgically  be  consid- 
ered to  extend  forwards  as  far  as  the  angle  of  the  jaw. 

Its  pulsations  are  in  reality  felt  beneath  its  own  border, 
or  immediately  beneath  its  sternal  and  clavicular  at- 
tachments.1 

Structures  superficial  to  the  Sterno-mastoid. — On  re- 
flecting the  skin  and  cellular  tissue  the  first  structure 
met  with  is  the  platysma,  passing  obliquely  backwards 
from  the  jaw  to  the  shoulder,  and  on  dissecting  off  this 
layer  of  muscular  tissue  from  above  downwards,  the 
structures  met  with  are,  some  filaments  of  the  small  oc- 
cipital nerve,  the  great  auricular  nerve,  the  external 
jugular  vein,  which  usually  crosses  the  muscle  obliquely 
at  about  its  middle,  to  pass  ultimately  into  the  subcla- 
vian  vein,  the  transverse  superficial  cervical  nerve,  pass- 
ing forwards  to  the  under  surface  of  the  platysma  and 
integument,  and  some  branches  of  the  descending  clavic- 
ular nerves.  The  disposition  of  the  fibres  of  the  pla- 
tysma, as  far  as  regards  the  direction  of  the  external 
jugular  vein,  is  important,  as  in  venesection  it  is  neces- 
sary to  cut  across  them,  and  not  in  their  continuity, 
otherwise  the  wound  would  close  from  muscular  con- 

1  According  to  Richet  it  is  impossible  to  puncture  the  common 
carotid  from  the  side  of  the  neck  without  perforating  the  sterno- 
mastoid  in  the  undissected  subject,  a  statement  I  have  taken  care 
to  verify. 


REGION    OF    THE    CAROTID    ARTERIES. 


83 


traction.  That  portion  of  the  cervical  aponeurosis  which 
forms  the  anterior  layer  of  the  sheath  of  the  muscle  is 
next  seen,  attached  above  to  the  angle  of  the  jaw  (almost 
appearing  to  divert  the  anterior  border  of  the  muscle 


Diagram  of  the  parts  seen  in  a  horizontal  section  through  the  sixth  cervical 
vertebra.  A.  Body  of  sixth  cervical  vertebra.  B.  Spinal  cord.  c.  Thyroid  car- 
tilage. r>.  Cricoid  cartilage.  E.  Sterno-hyoid  muscle.  F.  Omo-hyoid.  G.  Com- 
mon carotid  artery.  H.  Internal  jugular  vein.  K.  Platysma.  L.  Sterno-thyroid. 
M.  Opening  of  larynx.  N.  Inferior  constrictor,  o.  Summit  of  lateral  lobe  of 
thyroid  body.  p.  (Esophagus.  Q.  Thyro-arytenoid  muscle.  R.  Spinalis  colli. 
v.  Trapezius.  x.  Splenius.  Y.  Complexus.  d.  External  jugular  vein.  6.  Vagus 
nerve,  e.  Longus  colli.  /.  Scalenus  anticus.  m.  Sterno-cleido-mastoid.  n. 
Vertebral  vessels,  p.  Sympathetic,  s.  Descendens  noni. 

from  the  straight  line),  and  below  to  the  clavicle,  and 
to  the  corresponding  facial  sheath  of  the  opposite  mus- 
cle; and  after  completely  inclosing  the  muscle  at  its 
posterior  border,  it  becomes  continuous  with  the  apon- 
eurosis of  the  neck. 

The  sterno-cleido-mastoid  is  perforated  on  its  under 
surface,  near  the  centre,  by  the  spinal  accessory  nerve, 


84         SURGICAL  ANATOMY  OF  THE 

which  entering  it  obliquely,  after  inosculating  in  its  sub- 
stance with  the  second  and  third  cervical  nerves,  passes 
out  behind  its  posterior  border,  and  crosses  the  posterior 
triangular  space.  The  muscle  is  readily  seen  in  action, 
on  rotating  the  head,  or  on  bowing  it  upon  the  thorax, 
when  both  muscles  are  used. 

Parts  beneath  the  Sterno-cleido-mastoid. — Immediately 
behind  the  muscular  fibres  is  the  posterior  layer  of  the 
sheath  ;  and  between  it  and  the  muscle  lie  a  considerable 
number  of  lymphatics,  and  some  twigs  of  the  sterno- 
mastoid  branches  of  the  superior  thyroid  artery. 

The  most  convenient  method  of  grouping  the  structures 
which  lie  beneath  the  muscle  is  to  divide  it  into  three 
portions,  making  the  crossing  of  the  omo-hyoid  to  sepa- 
rate the  middle  and  lower,  and  a  line  drawn  backwards 
from  the  angle  of  the  jaw  to  separate  its  middle  and 
upper.  Beneath  the  posterior  layer  of  the  sheath  in  the 
upper  third,  from  above  downwards,  the  structures  met 
with  are, — the  insertion  of  the  splenius  capitis,  beneath 
which  are  the  attachments  of  the  posterior  belly  of  the 
digastric  and  of  the  trachelo-mastoid,  the  posterior  auricu- 
lar and  occipital  vessels,  the  external  border  of  the  corn- 
plexus,  while  still  deeper  are  the  attachments  to  the  atlas, 
of  the  obliqui  and  rectus  lateralis  muscles,  the  vertebral 
artery,  and  suboccipital  nerve.  In  the  middle  third, 
passing  obliquely  into  the  under  surface  of  the  muscle, 
is  the  spinal  accessory  nerve,  which  unites  with  some 
filaments  of  the  cervical  plexus ;  next  appear  a  chain 
of  lymphatic  glands  (glandules  concatenatce),  and  the 
branches  of  origin  of  the  superficial  cervical  plexus,  the 
descendens  and  cornmunicans  noni  nerves.  Beneath 
them  lie  the  common,  internal  and  external  carotid  arte- 
ries and  jugular  vein,  the  hypoglossal  nerve,  the  vagus, 


REGION    OF    THE    CAROTID    ARTERIES.  85 

the  superior  cervical  ganglion  of  the  sympathetic,  and 
deeper  down  upon  the  spinal  column  the  attachments  of 
the  rectus  anticus  major,  scaleni,  levator  anguli  scapulae, 
and  splenius  colli  muscles.  Next  is  the  crossing  of  the 
omo-hyoid,  and  in  the  inferior  third  from  within  outward, 
are  the  outer  borders  of  the  sterno-hyoid  and  thyroid 
muscles,  covered  by  their  aponeuroses,  with  the  nerves 
supplying  them.  Posteriorly  and  externally  are  the 
scaleni  and  the  cervical  plexus,  the  phrenic  branch  of 
which  lies  on  the  anterior  scalenus,  behind  which  is  the 
third  part  of  the  subclavian  artery,  having  the  ascending 
cervical  artery  lying  parallel  and  internal  to  it ;  a  quan- 
tity of  lymphatic  ganglia,  and,  inclosed  in  their  proper 
sheath,  lying  obliquely,  in  the  middle  of  this  space,  the 
common  carotid  artery  and  the  internal  jugular  vein 
which  joins  the  subclavian  vein  below;  into  the  junction 
of  which  pass,  on  the  right  side,  the  common  lymphatic 
trunk,  and  on  the  left  the  thoracic  duct  with  its  tribu- 
taries. Posteriorly,  are  the  vagus  and  the  recurrent 
laryngeal  nerves,  and  closer  down  on  the  spine  the  cord 
of  the  sympathetic  and  the  middle  cervical  ganglion, 
lying  on  the  prevertebral  aponeurosis.  Posterior  to  the 
carotid  vessels  and  below,  is  that  portion  of  the  subelavian 
artery  which  lies  internal  to  the  anterior  scalenus.  This 
vessel,  on  the  right  side,  arises  from  the  innominate,  and 
lies  immediately  behind  the  inferior  angle  of  the  diver- 
gence of  the  sternal  and  cleidal  origins  of  the  cleido- 
mastoid,  and  is  separated  from  the  sterno-clavicular  ar- 
ticulation and  origins  of  the  sterno-hyoid  and  thyroid 
muscles,  by  the  junction  of  the  internal  jugular  and  sub- 
clavian veins.  The  vagus  and  phrenic  nerves  lie  in  front 
of  it,  with  numerous  branches  of  the  sympathetic ;  whilst 
embracing  it,  and  passing  behind  it,  is  the  recurrent 

"  8 


86         SURGICAL  ANATOMY  OF  TUB 

laryngeal  nerve.  Behind  it  is  the  transverse  process  of 
the  seventh  cervical  vertebra,  and  internally  the  common 
carotid  itself;  below  and  externally,  this  portion  of  the 
subclavian  artery  is  in  relation  with  the  pleura. 

The  branches  of  the  subclavian  artery  being  normally 
derived  from  the  first  part  of  its  course,  it  follows  that 
on  the  right  side  these  branches  lie  beneath  the  clavicu- 
lar portion  of  the  sterno-cleido-mastoid  muscle ;  and  this 
fact,  added  to  the  mechanical  difficulty  of  reaching  it, 
forms  a  serious  obstacle  to  success  on  placing  a  ligature 
upon  it  in  this  situation.  In  the  event  of  the  operation 
being  undertaken,  it  should  be  tied  as  near  the  vertebral 
as  possible,  so  that  a  coagulum  may  be  formed  between 
this  point  and  the  origin  of  the  trunk. 

On  the  left  side  the  recurrent  laryngeal  is  not  in  rela- 
tion with  the  subclavian  artery  in  the  neck  (vide  Sub- 
clavian Artery). 

The  sheath  of  the  carotid  vessels  is  derived  from  the  deep 
cervical  fascia,  and  is  divided  by  a  septum  into  three 
compartments — the  inner  containing  the  artery,  the  ex- 
ternal the  vein,  and  the  posterior  the  vagus  nerve; 
whilst  either  on  it,  or  sometimes  in  it,  is  the  loop  formed 
by  the  descendens  and  communicantes  noni.  Beneath 
the  sterno-mastoid,  the  relations  and  course  of  the  right 
and  left  common  carotids  are  precisely  similar.  Their 
course  is  represented  by  a  line  drawn  from  the  sterno-cla- 
vicular  articulation,  to  the  external  aspect  of  the  upper 
border  of  the  thyroid  cartilage,  at  which  level  generally 
it  divides  into  external  and  internal  carotid. 

The  left  common  carotid  in  the  neck  is  a  little  deeper 
and  rather  longer  than  the  right. 

Relations  of  the  Cervical  Portion  of  the  Common  Caro- 
tid.— In  front:  Integument,  platysma,  sternal  origin  of 


REGION    OF    THE    CAROTID    ARTERIES.  87 

sterno-mastoid,  sterno-hyoid,  sterno-thyroid,  omo-hyoid, 
descendeus  noni,  artery  to  sterno-mastoid,  middle  and 
superior  thyroid,  lingual  and  facial,  and  anterior  jugular 
veins. 

Externally:  Internal  jugular  vein,  vagus  nerve,  and 
lymphatics. 

Internally:  Trachea,  thyroid  body,  recurrent  laryngeal 
nerve,  inferior  thyroid  artery,  larynx,  and  pharynx. 

Behind:  Prevertebral  muscles,  sympathetic,  inferior 
thyroid  artery,  and  recurrent  laryngeal  nerve. 

The  external  carotid  artery  is  given  off  from  the  main 
trunk,  usually  opposite  the  upper  border  of  the  thyroid 
cartilage;  it  is  at  first  a  little  internal  to,  and  in  front  of, 
the  internal  carotid,  and  passes  upwards  and  forwards, 
and  afterwards  a  little  backwards,  towards  the  angle  of 
the  jaw.  Up  to  the  level  of  a  line  drawn  from  the  mastoid 
process  to  the  hyoid  bone  the  artery  is  superficial,  but  at 
this  point  it  gets  deeper,  being  crossed  by  the  ninth 
nerve,  the  posterior  belly  of  the  digastric  and  stylo- 
hyoid  muscles  and  a  plexus  of  veins;  it  then  enters  the 
lower  border  of  the  parotid  gland  (vide  Parotid  Region). 

The  branches  of  the  external  carotid  are  usually  given 
off  in  the  following  order:  (1)  superior  thyroid;  (2) 
lingual ;  (3)  facial ;  (4)  occipital ;  (5)  posterior  auricular ; 
(6)  ascending  pharyngeal;  terminating  in  the  temporal 
and  internal  maxillary. 

Relations  of  External  Carotid. — In  front:  Integument, 
platysma,  and  fasciae,  sterno-mastoid,  hypoglossal  nerve, 
lingual  and  facial  veins,  posterior  belly  of  digastric  and 
stylo-hyoid  muscles,  and  parotid  gland. 

Behind:  Superior  laryngeal  nerve,  styloid  process, 
stylo-glossus  and  stylo-pharyngeus  muscles,  glosso- 


88         SURGICAL  ANATOMY  OF  THE 

pharyngeal  nerve,  and  that  portion  of  the  parotid  gland 
which  separates  it  from  the  internal  carotid. 

Internally:  Hyoid  bone,  pharynx,  parotid,  ramus  of 
jaw,  and  stylo-maxillary  ligament. 

Internal  Carotid  Artery  (cervical  portion). — Arises  op- 
posite the  upper  border  of  the  thyroid  cartilage,  and  is 
at  first  superficial  and  external  to  the  external  carotid, 
until  the  crossing  of  the  digastric,  where  it  becomes 
deeper  and  lies  beneath  the  external  carotid.  Usually 
it  gives  off  no  branches  in  the  neck,  and  is  larger  than 
the  external  in  the  child,  but  of  much  the  same  calibre 
in  the  adult. 

Relations  of  the  Cervical  Portion  of  the  Internal  Carotid. 
— In  front:  Integument  and  platysma,  sterno-mastoid, 
parotid,  hypoglossal  nerve,  styloid  process,  stylo-glossus, 
and  stylo-pharyngeus  muscles,  glosso-pharyngeal  nerve 
and  its  branches. 

Externally:  Internal  jugular  vein,  and  vagus  nerve. 

Internally:  Pharynx,  ascending  pharyngeal  artery. 

Behind:  Rectus  anticus  major  muscle,  sympathetic, 
and  superior  laryngeal  nerves. 

This  region  is  the  seat  of  most  important  operations— 
viz.,  ligature  of  the  common  carotid  arteries  or  their 
branches,  of  the  subclavian  in  the  first  part  of  its  course, 
of  the  innominata,  of  O3sophagotomy,  the  removal  of 
tumors,  and  opening  of  abscesses. 

Ligature  of  the  Common  Carotid  Artery. — In  applying 
a  ligature  to  the  common  carotid,  that  portion  of  it 
which  lies  either  immediately  above  or  immediately  be- 
low the  crossing  of  the  omo-hyoid  should  be  selected,  as 
the  vessel  is  there  most  easily  reached. 

Above  the  Omo-hyoid. — The  incision  to  be  made  varies 
in  length,  according  to  the  nature  of  the  case,  and  the 


REGION    OF    THE    CAROTID    ARTERIES. 


89 


depth  of  the  superjacent  structures,  but  is  usually  one 
about  three  inches  in  length,  along  the  anterior  border 


FIG.  14. 


r k 


&WS 


Common  carotid  artery  and  its  branches,  a.  Sterno-mastoid  reflected,  b. 
Glandulse  concatenate,  c.  Anterior  belly  of  digastric,  c'.  Posterior  belly  of  di- 
gastric, e.  Thyro-hyoid.  /.  Sterno-thyroid.  g.  Sterno-hyoid.  h.  Omo-hyoid. 
i.  Anterior  scalenus.  k.  Masseter.  I.  Submaxillary  gland,  m.  Parotid  gland. 
n.  Common  carotid,  n'.  Internal  jugular  vein  (joined  by  the  anterior  jugular 
and  supra-scapular),  o.  External  carotid,  p.  Internal  carotid,  r.  Facial,  r'. 
Facial  vein.  s.  Lingual,  t.  Superior  thyroid,  t'.  Nerve  to  thyro-hyoid.  u  u' . 
Vagus,  v'.  Spinal  accessory  nerve,  x.  Hypoglossal  nerve,  x'.  Descendens  noui 
nerve,  z.  Phrenic  nerve. 

of  the  sterno-mastoid,  from  just  below  the  angle  of  the 
jaw  to  the  cricoid  cartilage,  dividing  the  integument, 
superficial  fascia,  and  platysma,  and  the  wound  being 
kept  open  by  retractors;  the  deep  fascia  is  met  with, 
which  is  very  adherent  to  the  sheath  of  the  vessels;  a 
plexus  of  veins,  and  a  few  small  arterial  twigs,  are  often 


90         SURGICAL  ANATOMY  OF  THE 

interspersed  between  the  fascia  and  the  sheath.  This 
fascia  should  be  cautiously  divided  on  a  director,  so  as 
to  expose  the  sheath,  upon  or  beneath  which  is  the  de- 
scendens  noni  nerve. 

Next  a  small  portion  of  the  sheath  is  to  be  pinched 
up  and  "nicked/7  by  holding  the  blade  of  the  knife 
horizontally,  immediately  over  the  inner  aspect  of  the 
vessel,  as  far  from  the  vein  as  possible ;  and  an  aneurism 
needle  is  to  be  passed  from  without  inwards,  and  kept 
closely  round  the  artery,  so  as  to  avoid  wounding  the 
internal  jugular  vein  or  including  the  pneumogastric 
nerve.  There  is  a  tough  layer  of  areolar  tissue  between 
the  sheath  and  the  artery,  which  must  be  gently  "teased'7 
through,  by  the  needle,  on  being  pushed  against  the 
finger  nail.  The  jugular  vein  may  be  compressed  above 
and  below  during  the  operation,  as  it  is  liable  to  become 
suddenly  so  distended  as  to  conceal  the  parts.  Should 
any  difficulty  in  reaching  the  vessel  be  met  with,  owing 
to  engorgement  of  the  veins,  an  important  landmark 
will  be  found  in  the  anterior  tubercle  of  the  transverse 
process  of  the  sixth  cervical  vertebra,  which  is  behind 
and  a  little  internal  to  the  carotid  process,  and  against 
this  the  carotid  may  be  compressed. 

Below  the  crossing  of  the  Omo-hyoid. — Tying  the  vessel 
below  the  omo-hyoid  is  much  more  difficult,  owing  to  its 
greater  depth,  and  to  the  size  of  the  veins:  an  incision 
should  be  made  about  three  inches  in  length  from  the 
cricoid  cartilage,  along  the  anterior  border  of  the  sterno- 
cleido-mastoid  (which  is  to  be  drawn  outwards),  taking 
care  to  avoid  wounding  the  lower  sterno-mastoid  artery 
and  the  middle  thyroid  vein:  the  fascia  covering  the 
sterno-hyoid  and  sterno-thyroid  muscles  is  next  seen, 
and  must  be  cautiously  divided,  and  these  muscles 


REGION    OF    THE    CAROTID    ARTERIES.  91 

pulled  inwards,  the  sheath  being  reached  (upon  which 
are  branches  of  the  loop  of  the  descendens  and  communi- 
cans  noni  nerves),  it  is  to  be  opened,  and  the  needle 
passed  from  without  inwards.  The  inferior  thyroid 
artery  and  sympathetic  and  recurrent  laryngeal  nerves 
lie  immediately  behind  the  vessel  in  this  part  of  its 
course.  It  must  be  borne  in  mind  that,  on  the  right 
side  of  the  neck,  at  its  lower  part,  the  internal  jugular 
vein  diverges  from  the  artery;  but  on  the  left  approaches 
it,  and  sometimes  crosses  it,  owing  to  the  formation  of 
the  innominate  veins.  As  before  mentioned,  advantage 
may  be  taken  of  the  natural  interspace  between  the  two 
heads  of  origin  of  the  sterno-mastoid  to  place  a  ligature 
on  this  portion  of  the  vessel,  but  it  is  very  difficult  for 
the  reason  just  stated  (Sedillot).  Another  method  of 
reaching  it  is  to  expose  and  divide  the  sternal  attach- 
ment of  the  sterno-mastoid,  thereby  obtaining  greater 
room  and  corresponding  safety  (Malgaigne). 

Collateral  circulation  after  Ligature  of  the  Common  Caro- 
tid.— Supposing  the  vessel  to  be  normal — that  is  to  say, 
that  it  gives  off  no  branch  before  the  usual  bifurcation, 
the  collateral  circulation  is  very  free,  and  is  re-established 
by  vessels  both  without  and  within  the  cranium ;  thus, 
the  current  of  blood  being  arrested  in  the  carotid,  the 
subclavian  of  the  same  side  becomes  dilated,  the  work 
outside  the  skull  is  thrown  upon  the  inferior  thyroid 
branch  of  the  thyroid  axis,  the  superior  thyroid  branch 
of  the  external  carotid,  the  profunda  cervicis  of  the 
superior  intercostal,  and  the  princeps  cervicis  of  the  oc^ 
cipital ;  the  vertebral  doing  the  work  of  the  internal  car- 
otid, within  the  skull. 

Ligature  of  the  External  Carotid  Artery. — An  incision 
is  to  be  made  similar  to,  that  for  tying  the  common  car? 


92  SURGICAL    ANATOMY    OF 

otid  above  the  omo-hyoid,  where  the  vessel  is  most 
superficial,  and  immediately  beneath  the  skin,  platysma, 
and  superficial  fascia,  and  a  complicated  plexus  of  veins. 
The  posterior  belly  of  the  digastric  and  its  attendant 
muscle,  the  stylo-hyoid,  should  be  drawn  upwards 
towards  the  jaw,  and  the  sterno-mastoid  outwards ;  the 
superior  laryngeal  branch  of  the  vagus  lies  usually  just 
behind  its  short  trunk. 

The  collateral  circulation  after  ligature  of  the  external 
carotid  would  be  readily  maintained  by  its  branches 
anastomosing  so  freely  on  the  face  with  those  of  the  op- 
posite side,  and  by  the  terminal  branches  of  the  inter- 
nal carotid  (supra-orbital,  ethmoidal,  palpebral,  and 
nasal)  with  the  facial,  and  by  the  profunda  and  princeps 
cervicis. 

(This  operation  is  not  often  resorted  to  in  the  prac- 
tice of  surgery,  as  it  is  preferable  to  tie  the  common 
trunk.) 

Tenotomy. — The  attachments  of  the  sterno-cleido- 
mastoid  to  the  clavicle  and  sternum  occasionally  require 
division,  subcutaneously,  for  the  relief  of  wryneck  or  tor- 
ticollis, and  considerable  caution  is  requisite  in  this  ap- 
parently simple  operation,  as  there  is  a  danger  of  wound- 
ing the  external  jugular  vein  as  it  passes  into  the  internal 
jugular,  or  even  more  important  vessels,  if  it  be  clumsily 
or  hastily  performed. 

SURGICAL  ANATOMY  OF  THE  SUBCLAVIAN  REGION 

(OR  REGION  OF  THE  THIRD  PART  OF  THE 

SUBCLAVIAN  ARTERY). 

This  region  receives  its  name  from  the  fact  of  its  con- 
taining the  third  portion  of  the  subclavian  artery,  and 
on  account  of  its  being  the  most  common  seat  of  opera- 


THE    SUBCLAVIAN    REGION.  93 

tioii  upon  that  vessel,  but  from  its  actual  position  and 
natural  boundaries  it  would  be  more  correctly  termed 
supra-clavicular.  The  hollow  which  exists  above  and 
behind  the  clavicle  is  almost  invariably  well  marked, 
even  where  there  is  much  fat  in  the  neck ;  and  it  is  this 
space,  with  its  numerous  contents  and  varying  confor- 
mation, which  is  of  such  surgical  import.  It  is  bounded 
anteriorly  by  the  posterior  border  of  the  sterno-cleido- 
mastoid ;  behind,  by  the  rounded  anterior  border  of  the 
trapezius — -these  muscles  nearly  meet  above  at  their  cra- 
nial attachment,  where  their  aponeuroses  are  blended ; 
below  by  the  clavicle,  and  above  by  the  crossing  of  the 
posterior  belly  of  the  omo-hyoid,  and  its  floor  is  formed 
by  the  first  rib  and  the  muscular  structures  attached 
to  it. 

The  pulsation  of  the  subclavian  artery  can  be  felt  at 
the  bottom  of  the  space  as  it  crosses  the  first  rib,  against 
which  it  can  be  readily  controlled  for  any  operation 
about  the  shoulder  or  arm.  The  positions  of  the  scalene 
muscles,  the  cords  of  the  brachial  plexus,  particularly 
those  of  the  fifth  and  sixth,  and  the  course  of  the  omo- 
hyoid,  are  also  felt,  and  generally  to  be  seen,  as  emi- 
nences beneath  the  integument.  It  must  be  borne  in 
mind  that  the  "  triangle"  formed  by  the  crossing  of  the 
omo-hyoid  is  a  result  of  dissection,  and  the  detachment 
of  its  aponeurosis ;  no  such  regular  interspace  existing 
during  life,  the  inner  border  of  the  muscle  lying  behind 
the  clavicle,  and  its  upper  border  only  being  seen  whilst 
in  action.  The  change  in  the  appearance  of  the  hollow 
immediately  above  and  behind  the  clavicle  is  noticeable 
under  certain  circumstances;  thus,  in  inspiration,  it  is 
considerably  deepened,  and  during  expiration  becomes 
flatter,  when  the  pulse  in  the  subclavian  vein  is  gener- 


SURGICAL    ANATOMY    OF 


ally  visible.     Again,  the  various  movements  of  the  arm 
and  of  the  clavicle  cause  considerable  modifications  of 


FIG.  15. 


IV 13 


Diagrammatic  section  through  the  centre  of  the  right  clavicle,  showing  the 
relation  of  the  subclavian  vessels  in  their  antero-posterior  direction.  1.  Subola- 
vian  artery.  2  Suholavian  vein.  3.  Anterior  scalenus  muscle.  4.  First  rib.  5.  Pec- 
toralis  major.  6.  Subclavius  muscle.  7.  Clavicle.  8.  Cords  of  brachial  plexus. 
9.  Scalenus  medius.  10.  Transversalis  colli  artery.  11.  Trapezius.  12.  Levator 
anguli  scapulae.  13.  Rhomboid.  14.  Cavity  of  thorax. 

its  form,  and  the  relations  of  its  contents — a  circum- 
stance of  great  importance  to  the  surgeon. 

Compression  of  the  subclavian  artery  is  generally  neces- 
sary in  amputations  about  the  upper  arm,  and  very 
slight  pressure  is  requisite.  The  thumb  or  finger  is  to  be 
slipped  just  behind  the  posterior  border  of  the  sterno- 
mastoid,  where  it  is  attached  to  the  clavicle,  and  on  slight 
pressure  being  made  in  a  vertical  direction  to  the  axis  of 
the  body,  the  pulsation  of  the  vessel  is  felt ;  a  little  fur- 
ther pressure  at  the  pulsating  point  compresses  it  against 
the  first  rib,  and  does  not  interfere  with  the  circulation 
in  the  subclavian  vein.  The  circulation  may  be  con- 


THE    SUBCLAVIAN    REGION.  95 

trolled  also,  in  many  instances,  by  drawing  the  arm  back- 
wards, and  forcibly  depressing  the  tip  of  the  shoulder. 

Dissection. — After  removing  the  skin,  superficial  fas- 
cia, and  the  posterior  fibres  of  the  platysma,  with  the 
thin  fascia  immediately  beneath  this,  the  handle  of  the 
knife  will  be  generally  found  sufficient  to  expose  all  the 
important  relations.  The  first  structures  met  with,  are 
the  descending  superficial  branches  of  the  cervical 
plexus  (the  acromial  and  clavicular),  and  a  considerable 
number  of  lymphatic  glands.  Beneath  the  layer  of  the 
cervical  fascia  which  covers  in  the  space  is  a  quantity  of 
loose  cellular  tissue  and  fat,  in  which  lie  lymphatics 
and  superficial  cutaneous  and  glandular  vessels.  The 
upper  border  of  the  omo-hyoid,  inclosed  in  its  sheath  of 
deep  cervical  fascia,  is  next  met  with,  the  anterior  layer 
binding  down  the  subclavian  vein  against  the  clavicle, 
which  vein  here  receives  the  external  jugular  just  be- 
hind the  attachment  of  the  sterno-cleido-mastoid.  Im- 
mediately behind  the  vein,  internally,  is  the  anterior 
scalene  muscle;  and  emerging  from  behind  it,  and  meet- 
ing the  vein  at  an  acute  angle  in  a  plane  superior  to  it, 
is  the  subclavian  artery ;  and  in  a  plane  more  posterior, 
but  above,  are  the  cords  of  the  brachial  plexus.  The 
anterior  scalene  muscle  is  inserted  into  a  tubercle  (the 
scalene  tubercle)  on  the  first  rib,  which  is  a  guide  to  the 
vessel,  and  in  front  of,  and  behind  the  tubercle  are 
grooves  on  the  rib,  in  which  lie,  in  the  anterior,  the  sub- 
clavian vein,  and,  in  the  posterior,  the  subclavian  artery, 
separated  from  each  other  by  the  muscle.  The  supra- 
scapular  artery,  a  branch  of  the  subclavian  in  the  first 
part  of  its  course  (normally),  with  its  vein,  crosses  the 
main  trunk  just  below  the  crossing  of  the  omo-hyoid, 
and  lies  along  the  upper  border  of  the  clavicle.  The 


96 


SURGICAL    ANATOMY    OF 


transversalis  colli  artery,  also  a  branch  of  the  main 
trunk  in  the  first  part  of  its  course,  lies  superior  to  the 


Region  of  the  third  part  of  the  subclavian  artery  (the  shoulder  represented 
depressed).  A.  Splenius.  B.  Levator  anguli.  c.  Scalenus  posticus.  D.  First 
serration  of  serratus  magnus.  K.  Costo-coracoid  membrane  and  cephalic  vein. 
F.  Subclavian  artery.  G.  Transversalis  colli  artery  (deep).  H.  A  more  super- 
ficial branch,  i.  Supra-scapular  artery.  K.  Subclavian  vein.  L.  Supra-scapular 
vein.  M.  Brachial  plexus.  N.  Scalenus  anticus.  o.  Phrenic  nerve. 


artery,  but  beneath  the  cervical  plexus  it  passes  towards 
the  trapezius,  to  reach  the  posterior  border  of  the  scap- 
ula. These  vessels  are  accompanied  by  veins  forming 
a  plexus,  which  lies  superficial  to  the  artery,  and  may 
cause  considerable  difficulty  in  any  operation  in  this 
region,  especially  when  engorged. 


THE    SUBCLAVIAN    REGION.  97 

The  relations  of  the  subdavian  artery  in  the  third  part 
of  its  course  are  : 

In  front. — Integument,  superficial  cervical  fascia,  pla- 
tysma,  external  jugular  vein,  and  the  venous  plexus 
before  mentioned,  descending  cervical  nerves,  subclavius 
muscle,  supra-scapular  artery,  and  clavicle. 

Above. — Brachial  plexus,  and  posterior  belly  of  omo- 
hyoid  muscle. 

Below. — First  rib,  covered  by  the  first  serration  of  the 
serratus  magnus. 

Behind. — The  middle  scalene  muscle. 

Ligature  of  the  Subdavian  Artery  in  the  third  part  of  its 
course. — The  point  selected  for  placing  a  ligature  upon 
this  vessel,  is  just  where  it  lies  on  the  first  rib,  at  the 
bottom  of  the  hollow  above  described.  It  is  not  inclosed 
in  a  definite  sheath  like  the  carotid,  but  is  bound  down 
by  a  process  of  the  deep  cervical  fascia,  derived  from  the 
aponeurotic  investment  of  the  omo-hyoid.  The  incision 
is  most  advantageously  made,  by  drawing  the  integu- 
ment down,  and  cutting  upon  the  clavicle,  allowing  it  to 
retract  afterwards;  but  this  proceeding  must  be  modified 
by  circumstances.  When  the  vessel  is  reached,  just  as 
it  emerges  from  behind  the  anterior  scalene  muscle,  the 
needle  must  be  passed  round  it  from  before,  backwards  ; 
and  the  end  of  the  needle  must  be  made  to  insinuate 
itself  round  the  vessel  closely,  so  as  to  avoid  the  united 
cord  of  the  eighth  cervical  and  first  dorsal  nerves,  which 
lie  immediately  behind  it. 

The  collateral  circulation  developed  after  ligature  of  the 
third  part  of  the  subdavian  artery  is  as  follows  : 

As  the  third  portion  rarely  gives  off  any  branches,  the 
blood  would  pass  towards  the  arm  by  the  supra-scapular 
and  posterior  scapular  branches  of  the  thyroid  axis, 


98  SURGICAL    ANATOMY    OF 

anastomosing  directly  with  the  dorsalis  scapulae  of  the 
axillary,  on  the  dorsum  scapulae.  The  internal  mam- 
mary trunk  of  the  subclavian  anastomoses  with  the 
acromio-thoracic,  long  thoracic,  and  subscapular,  and  the 
superior  intercostal  with  the  superior  thoracic. 

SUKGICAL  ANATOMY  OF  THE  INNOMINATA. 

Although  the  innominate,  anatomically  speaking,  be- 
longs to  the  thorax,  yet  any  surgical  proceeding  in  con- 
nection with  it  would  be  attempted  in  the  lower  part  of  the 
carotid  region ;  hence  it  has  been  thought  advisable  to 
introduce  it  into  the  surgical  anatomy  of  the  neck. 

In  the  neck  it,  normally,  ascends  obliquely  in  the  right 
side  to  the  posterior  aspect  of  the  sterno-clavicular  articu- 
lation, where  it  divides  into  the  right  subclavian  and 
common  carotid  arteries,  and  is  about  an  inch,  or  rather 
more,  in  length. 

Relations.  —  From  before  backwards  the  structures 
covering  it  are — skin,  fascia,  some  fibres  of  platysma, 
and  descending  branches  of  cervical  plexus,  sternal  origin 
of  sterno-mastoid,  a  portion  of  the  manubrium  sterni, 
origins  of  the  sterno-hyoid  and  sterno-thyroid  muscles, 
remains  of  thymus  gland,  left  innominate,  and  right  in- 
ferior thyroid  veins,  and  cardiac  branches  of  vagus. 

On  its  right  side  lie  the  right  innominate  vein,  vagus, 
and  pleura ;  on  its  left,  the  remains  of  the  thymus  gland, 
and  commencement  of  the  left  common  carotid ;  and 
behind  it  is  the  trachea.  It  occasionally  divides  higher 
in  the  neck  than  at  the  sterno-clavicular  articulation,  and 
may  be  seen  pulsating.  Its  position  must  be  carefully 
made  out  in  performing  tracheotomy,  particularly  in 
children,  where  the  space  in  which  the  operation  is  feasi- 
ble is  very  limited,  and  the  structures  so  close  together, 


THE    INNOM1NATA.  99 

besides  which  the  trachea  is  very  small  and  movable. 
It  sometimes  gives  off  a  branch  to  the  thyroid  body 
(the  thyroidea  ima),  which  might  lie  immediately  over 
the  site  of  the  deep  incision  in  tracheotomy ;  and  occa- 
sionally it  gives  off  thymic  and  bronchial  branches. 

Ligature  of  the  Innominata. — In  order  to  expose  the 
vessel  for  the  purpose  of  ligaturing  it,  it  must  be  drawn 
out  as  much  as  possible  from  the  deep  position  it  occupies, 
by  raising  the  shoulders  and  throwing  back  the  head. 
Next,  the  sternal  origin  of  the  sterno-cleido-mastoid  is 
to  be  exposed,  by  an  incision  along  its  anterior  border, 
met  by  one  along  the  upper  edge  of  the  sternum  ;  this 
tendon  is  to  be  divided,  and  the  underlying  origins  of 
the  sterno-hyoid  and  thyroid  muscles  carefully  divided. 
Beneath  these  muscular  fibres  is  a  plexus  of  veins,  chiefly 
derived  from  the  inferior  thyroid,  which  must  be  hooked 
aside.  The  deep  cervical  fascia  is  next  to  be  cautiously 
scraped  through,  and  the  origin  of  the  common  carotid 
exposed,  which  vessel  serves  as  the  guide  to  the  trunk 
of  the  innominate.  The  left  innominate  vein  must  be 
drawn  down,  whilst  the  right  innominate  and  internal 
jugular  veins,  with  the  vagus  nerve,  are  to  be  drawn 
outwards.  The  needle  must  be  passed  from  below,  up- 
wards and  inwards,  taking  care  that  it  is  kept  close  to 
the  vessel,  to  avoid  wounding  the  right  pleura,  or  trachea 
which  lie  behind  it.  The  ligature  should  be  applied  as 
high  up  as  possible. 

Collateral  Circulation  developed  after  Ligature  of  the 
Innominata. — The  right  side  of  the  head  and  neck  would 
be  supplied  with  blood  by  the  inosculation  of  the  carotids 
with  those  of  the  opposite  side ;  and  the  circulation  in 
the  right  subclayiaii  would  b$' '  reestablished;  b^means 
of  its  intercostal  branch  inosculating  with  the  first  aortic 


100          SURGICAL  RELATIONS  OF 

intercostal,  assisted  by  the  internal  mammary  and  inter- 
costal arteries,  inosculating  with  the  long  thoracic,  supe- 
rior thoracic,  and  acromio-thoracic,  and  by  the  inoscula- 
tion between  the  superior  thoracic  and  deep  epigastric. 

SURGICAL  RELATIONS  OF  THE  (ESOPHAGUS  IN 
THE  NECK. 

The  oesophagus  is  occasionally  the  seat  of  operation, 
such  as  for  the  removal  of  some  foreign  body,  of  the  pass- 
ing of  bougies  in  cases  of  stricture,  or  introducing  the 
tube  of  a  stomach-pump.  The  operation  of  ossophagotomy 
is  required  but  rarely,  but  it  may  be  had  recourse  to  in 
such  cases  as  impaction  of  foreign  bodies,  when  the  sub- 
stance can  neither  be  pulled  out  through  the  mouth,  nor 
pushed  downwards  into  the  stomach,  or  in  such  a  case  as 
where  a  substance  might  be  removed  through  a  longi- 
tudinal wound  in  the  oesophagus,  but  could  not  be  drawn 
through  the  more  constricted  portion  of  the  tube — as, 
for  instance,  a  set  of  false  teeth,  &c.  In  the  neck,  it 
commences  as  a  constriction  below  the  pharynx,  having 
at  this  point  the  cricoid  cartilage  in  front,  and  the  fifth 
cervical  vertebra  behind  it. 

Just  at  first,  it  lies  in  the  mesial  line  of  the  body,  but 
as  it  approaches  the  root  of  the  neck  it  inclines  towards 
the  left  side. 

Relations. — In  front  of  it  lies  the  trachea,  and  after  it 
tends  to  the  left  side,  the  left  lobe  of  thyroid  body,  and 
the  thoracic  duct. 

Behind,  the  cervical  vertebrae  and  left  longus  colli 
muscle. 

At  the  sides,  the  common  carotid  vessels,  particularly 
the  left,  ;th&  thyroid  body;  and-  the J  recurrent  laryngeal 
nerves. 


THE    (ESOPHAGUS    IN    THE    NECK.  101 

Great  care  must  be  taken,  in  passing  bougies  or  tubes 
through  the  mouth  into  the  oesophagus,  to  keep  the  end 
of  the  instrument  well  against  the  spine,  and  to  use  very 
gentle  pressure,  as  false  passages  are  readily  made  (es- 
pecially where  there  has  been  any  disease)  into  the  pleural 
cavity,  posterior  mediastinum,  or  pericardium. 

The  operation  of  cesophagotomy  is  thus  performed.  An 
incision  is  to  be  made  on  the  left  side  of  the  neck,  about 
four  inches  long,  along  the  anterior  border  of  the  sterno- 
mastoid,  as  though  for  ligaturing  the  common  carotid 
artery  above  the  crossing  of  the  omo-hyoid.  The  omo- 
hyoid,  sterno-hyoid,  and  sterno-thyroid  muscles  are  to 
be  drawn  downwards  and  inwards,  and  the  sheath  of 
the  vessels,  uninvolved,  drawn  outwards ;  the  oesophagus 
is  then  seen  at  the  bottom  of  the  wound,  when  a  longi- 
tudinal incision  is  to  be  made  upon  the  foreign  body  or 
bougie  as  it  lies  in  the  tube. 

The  structures  to  be  avoided  are — the  sheath  of  the 
vessels,  the  thyroid  vessels,  the  thyroid  body,  and  the 
laryngeal  nerves. 

The  occipital  portion  of  the  side  of  the  neck,  that  above 
the  crossing  of  the  omo-hyoid,  possesses  few  points  of 
surgical  importance  beyond  it  being  the  seat  of  tumors. 
Its  boundaries  are — in  front,  the  stern o-mastoid ;  behind, 
the  trapezius ;  and  below,  the  omo-hyoid ;  its  floor  is 
formed  by  the  upper  portion  of  the  anterior  scalene 
muscle,  the  middle  and  posterior  scalene,  the  levator 
anguli  scapulae  and  splenius  colli  muscles.  The  spinal 
accessory  nerve  emerges  from  the  junction  of  the  upper 
and  middle  third  of  the  posterior  border  of  the  sterno- 
mastoid  and  crosses  the  region  obliquely,  to  enter  the 
trapezius,  accompanied  by  descending  muscular  branches 
of  the  cervical  plexus ;  the  superficial  branches  of  the 


102    REGION  OF  THE  NAPE  OF  THE  NECK. 

cervical  plexus  are  seen,  passing  upwards  (small  occipi- 
tal) along  the  posterior  border  of  the  sterno-mastoid, 
forwards  (great  auricular  and  transverse  cervical)  across 
it,  and  downwards  (descending  cervical).  There  are  a 
great  many  lymphatic  ganglia  along  the  posterior  border 
of  the  muscle,  and  the  integument  is  very  tough  and 
fibrous. 


KEGION  OF  THE  NAPE  OF  THE  NECK  (POSTERIOR 
CERVICAL  REGION). 

This  region  extends  from  the  occipital  tuberosity  and 
superior  curved  lines  above,  to  the  seventh  cervical  ver- 
tebra below,  and  is  bounded  laterally  by  the  trapezius. 
The  spinous  processes  of  the  three  last  can  be  felt  through 
the  integument,  the  seventh  receiving  the  name  of  ver- 
tebra prominens.  The  integument  is  very  tough  and 
strong,  containing  a  great  deal  of  fibrous  tissue,  and  not 
very  vascular,  and  is  a  favorite  seat  of  abscess  or  car- 
buncle ;  the  subcutaneous  cellular  tissue  contains  a  good 
deal  of  fat,  and  is  united  to  the  ligamentum  nuchse,  a 
tough  fibro-elastic  mass  extending  from  the  occipital 
tubercle  to  the  seventh  cervical  vertebra,  separating  the 
muscles  on  either  side  of  the  neck.  Beneath  the  apo- 
neuroses  lie  the  trapezius,  the  aponeurotic  attachment  of 
which  superiorly  is  blended  with  that  of  the  sterno-mas- 
toid ;  and  separating  these  muscles  from  the  succeeding 
layer  is  a  dense  fascia,  continuous  with  the  dorsal  apo- 
neurosis,  beneath  which  are  found  the  splenius  capitis 
and  the  levator  anguli  scapulae,  the  upper  portion  of  the 
rhomboidei,  and  serratus  posticus  superior;  next  the 
complexus,  the  trachelo-mastoid,  and  transversalis  colli. 
In  the  fat  and  cellular  tissue  beneath  this  layer  are 


REGION  OF  THE  NAPE  OF  THE  NECK.    103 

several  vessels  of  importance  in  the  maintenance  of  the 
collateral  circulation  after  ligature  of  the  subclavian  or 
carotid  arteries — namely,  the  occipital,  vertebral,  pro- 
funda,  and  princeps  cervicis.  The  occipital  enters  the 
region  between  the  splenius  capitis  and  obliquus  superior, 
and  lies  between  the  splenius  and  the  complexus,  and  is 
afterwards  distributed  to  the  scalp;  its  descending  branch, 
the  princeps  cervicis,  which  inosculates  with  the  vertebral 
and  the  profunda  cervicis  branch  of  the  superior  inter- 
costal, passes  between  the  complexus  and  semi-spinal  is 
colli  muscles.  The  profunda  cervicis  enters  the  region 
by  passing  backwards  between  the  transverse  process  of 
the  seventh  cervical  vertebra  and  the  first  rib.  The 
nerves  found  here  are  branches  of  the  suboccipital  and 
the  posterior  branches  of  the  great  occipital,  and  third 
and  fourth  cervical  nerves.  Beneath  the  integument  are 
a  number  of  lymphatic  ganglia,  which  become  engorged 
in  constitutional  syphilis.  Beneath  the  cellulo-fatty  layer 
are  the  muscles  forming  the  suboccipital  triangle,  the 
recti  capitis  postici,  internally,  the  obliquus  superior  and 
the  obliquus  inferior,  the  floor  of  which  triangle  contains 
the  curve  of  the  vertebral  artery  perforating  the  pos- 
terior occipito-atlantoid  ligament,  before  it  takes  its 
course  through  the  foramen  magnum ;  and  between  this 
vessel,  and  the  groove  in  the  atlas,  is  the  trunk  of  the 
suboccipital  nerve. 

Owing  to  the  curvature  of  the  cervical  spine,  the 
prominence  of  the  second  and  third  cervical  vertebra  is 
seen  in  the  pharyngeal  cavity,  and  can  be  readily  recog- 
nized from  the  mouth. 

The  cervical  spine  is  liable  to  dislocation  from  the 
great  mobility  of  the  articulations ;  and  from  the  fact 
that  the  articular  surfaces  are  nearly  horizontal,  disloca- 


104    REGION  OF  THE  NAPE  OF  THE  NECK. 

tion  without  fracture  may  take  place.  In  the  space 
between  the  first  cervical  vertebra  and  the  occiput  the 
cord  may  be  readily  reached  by  a  mere  puncture.  An 
injury  to  the  cord  above  the  third  would  implicate  the 
phrenic  nerve  and  paralyze  the  diaphragm,  and  give  rise 
to  sudden  asphyxia,  causing  instantaneous  death. 

If  the  lower  portion  of  the  cervical  cord  be  divided 
there  will  be  paralysis  both  of  the  upper  and  lower  ex- 
tremities, and  the  respiration  would  be  entirely  carried 
on  by  the  diaphragm.  If  the  injury  be  opposite  the 
sixth  cervical  vertebra,  there  would  be  only  partial  par- 
alysis of  the  upper  extremity,  owing  to  that  portion  of 
the  brachial  plexus  given  off  from  the  cord  above  this 
spot  being  unimplicated. 

The  cervical  spine  is  occasionally  the  seat  of  spina 
bifida,  an  arrest  of  development  in  which  the  spinous 
processes  or  the  laminae  are  absent  or  separated,  allowing 
of  the  bulging  of  the  meninges  beneath  the  integuments. 
In  spina  bifida  in  this  region,  the  spinal  cord  and  its 
nerves  are  generally  adherent  to  the  parietes  of  the 
tumor. 

The  relation  of  the  structures  passing  through  the 
superior  aperture  of  the  thorax  would  seem  to  form  a 
suitable  connection  between  the  regions  of  the  thorax  and 
neck.  Supposing  a  section  be  made — a  decapitation,  in 
fact — following  a  plane  passing  through  the  upper  part 
of  the  first  dorsal  vertebra  behind,  the  upper  borders  of 
the  first  ribs  laterally,  and  the  manubrium  sterni  ante- 
riorly, the  following  structures  would  be  seen  passing 
from  before  backwards,  between  the  apices  of  the  lungs. 
In  the  middle  line  are  the  origins  of  the  sterno-hyoid  and 
sterno-thyroid  muscles,  and  a  lax  cellular  tissue,  in  which 
are  the  remains  of  the  thymus  gland  and  inferior  thyroid 


REGION    OP    THE    NAPE    OF    THE    NECK.          105 

veins,  the  trachea,  oesophagus ;  and,  in  the  groove  sepa- 
rating them,  the  recurrent  laryngeal  nerves  ;  and  on  the 
left  side  the  thoracic  duct.  At  the  sides  the  internal 
mammary  vessels,  the  innominate  veins,  and  on  the  right 
the  innominate  artery,  with  the  vagus  nerve  lying  be- 


Median  Line. — 1.  Sterno-hyoid  muscles.  2.  Sterno-thyroid  muscles.  3.  Re- 
mains of  thymus  gland.  4.  Trachea.  5.  (Esophagus.  6.  Longi  colli  muscles. 
LeftSide. — 7.  Internal  mammary  artery.  8.  Innominate  vein.  9.  Phrenic  nerve. 
10.  Vagus  uerve.  11.  Recurrent  laryngeal  nerve.  12.  Cardiac  nerves.  13.  Left 
carotid  artery.  14.  Left  subclavian  artery.  15.  Thoracic  duct.  16.  Apex  of  lung 
and  pleura.  17.  Sympathetic.  18.  Superior  intercostal  artery.  19.  First  dorsal 
nerve.  Right  Side. — 20.  Internal  mammary  artery.  21.  Innominate  vein.  22. 
Phrenic  nerve.  23.  Vagus  ne"rve.  24  Cardiac  nerves.  25.  Innominate  artery. 
26.  Apex  of  lung  and  pleura.  27.  Sympathetic.  28.  Superior  intercostal  artery. 
29.  First  dorsal  nerve.  (HEATH.) 

tween  it  and  the  innominate  vein,  and  on  the  left  the 
common  carotid  and  subclavian  arteries,  with  the  vagus 
between  them,  the  phrenic  and  cardiac  nerves,  the  trunk 
of  the  sympathetic,  the  longi  colli  muscles,  and  the  su- 
perior intercostal  arteries  and  first  dorsal  nerves. 


106  SURGICAL    ANATOMY    OP 


CHAPTER  III. 

SURGICAL  ANATOMY  OF  THE  THORAX. 

IN  the  region  of  the  thorax  it  is  intended  to  include 
that  portion  of  the  body  comprising  the  parietes  of  the 
chest,  which  contains  the  heart,  lungs,  and  the  contents 
of  the  posterior  mediastinum,  and  is  bounded,  superiorly, 
by  the  superior  aperture  of  the  thorax  (that  is  to  say,  the 
bony  ring  formed  behind,  by  the  body  of  the  first  dorsal 
.vertebra,  on  either  side,  by  the  first  ribs,  and  anteriorly, 
by  the  upper  part  of  the  manubrium  sterni) ;  inferiorfy, 
by  the  diaphragm ;  and  laterally,  by  the  ribs  and  inter- 
costal muscles,  above  the  limit  of  the  diaphragm,  to  the 
exclusion  of  such  structures  as  are  regarded  as  belonging 
to  the  upper  extremity — namely,  those  entering  into  the 
formation  of  the  axilla,  which  region  will  be  hereafter 
described. 

The  applied  anatomy  of  the  thorax  is  rather  the  prov- 
ince of  the  physician  than  the  surgeon,  yet  at  the  same 
time  there  is  so  much  in  common  that,  with  regard  to 
physical  examination,  it  will  be  advisable  to  devote 
some  little  space  to  the  subject. 

Before  going  into  any  details  of  its  structure  it  is  nec- 
essary to  point  out  the  relations  of  its  contents  with 
reference  to  the  walls  of  the  chest — such  in  fact  as  relate 
to  the  auscultation  or  percussion  of  the  lungs,  heart,  and 
great  vessels.  As,  however,  these  matters  are  to  be 


THE    THORAX.  107 

found  in  works  specially  devoted  to  the  subject,  it  is 
proposed  merely  to  point  out  the  chief  anatomical  bear- 
ings of  the  contained  viscera. 

The  Lungs. — Presuming  the  body  to  be  normal,  their 
position  with  regard  to  the  thoracic  walls  is  as  follows  : 
The  apices  lie  beneath  the  scalenus  anticus  muscle  and 
the  subclavian  artery,  separated  by  the  oesophagus,  tra- 
chea, and  anterior  portion  of  the  bodies  of  the  first  and 
second  dorsal  vertebrae.  The  bases  of  each  are  separated 
from  the  abdominal  viscera  by  the  diaphragm,  that  of 
the  right  being  considerably  hollowed  out  by  the  bulg- 
ing upwards  of  the  liver,  as  far  up  in  the  thorax  as  the 
fifth  rib  ;  that  of  the  left  is  hollowed  out  to  a  less  degree 
by  the  projection  of  the  stomach,  spleen,  and  left  lobe  of 
liver. 

The  inner  margin  of  the  right  lung  passes  vertically 
down  the  middle  of  the  sternum,  with  a  slight  inclina- 
tion to  the  same  side,  as  far  as  the  sterno-xiphoid  articu- 
lation. 

The  inner  margin  of  the  left  lung  lies  parallel  with  that 
of  the  right,  about  as  far  as  to  the  fourth  costal  carti- 
lage, where  it  passes  outwards  along  this  cartilage  for  a 
short  distance,  and  then  descends  obliquely  downwards 
and  backwards,  a  little  internal  to  the  nipple,  nearly  as 
far  as  the  seventh  rib. 

The  Heart. — The  heart  lies  obliquely,  and  during  ex- 
piration is  nearly  horizontal,  its  base  being  to  the  right 
and  apex  to  the  left  side.  The  base  corresponds  to  the 
interval  between  the  fifth  and  eighth  dorsal  vertebrae, 
and  its  apex  to  a  little  below  the  left  fifth  rib,  to  the 
left  of  its  junction  with  its  cartilage,  while  the  impulse 
is  to  be  felt  in  the  interspace  between  the  cartilages  of 
the  fifth  and  sixth  ribs,  internal  to  the  nipple.  Its 


108  SURGICAL    ANATOMY    OF 

upper  border  corresponds  to  a  line  on  a  level  with  the 
upper  borders  of  the  third  costal  cartilages.,  and  its  lower 
border  to  a  line  extending  between  the  articulation  of  the 
ensiform  with  the  costal  cartilage  on  the  right  side,  to 
the  position  of  the  apex.  Hence,  for  auscultation  of  the 
base,  the  spot  is  the  upper  border  of  the  third  costal  car- 
tilage, and  for  the  apex,  a  point  about  two  inches  below 

FIG.  18. 


-----  9 


Diagram  of  the  relatiocs  of  the  thoracic  viscera  to  the  walls  of  the  chest 
(altered  from  ANGER).  1.  Situation  of  pulmonary  orifice.  2.  Left  auriculo- 
ventricular  orifice.  3.  Orifice  of  aorta.  4.  Right  auriculo-ventricular  orifice. 

5.  Limit  of  the  anterior  and  inferior  border  of  left  lung  in  complete  expiration. 

6.  Ditto  of  right  lung.    7.  Limit  of  left  lurg  in  inspiration.    8.  Ditto  of  right 
lung  in  inspiration.    9.  Limit  of  pleura.    10.  Ditto.    11.  Superior  cul-de-sac  of 
left  lung.    12.  Ditto  of  right  lung.    13.  Right  auricle.    14.  Right  auricular  ap- 
pendage.   15.  Left  auricle.    16.  Limit  of  diaphragm  in   complete  expiration. 
17.  Ditto,  ditto.    18.  Ditto,  ditto,  in  complete  inspiration. 

the  nipple,  and  one  inch  towards  the  middle  line  of  the 
body. 

The  right  auriculo-ventricular  opening  is  behind  the 


THE    THORAX.  109 

centre  of  the  sternum,  on  a  line  with  the  lower  margin 
of  the  articulation  of  the  cartilage  of  the  fourth  rib  with 
it.  The  left  auriculo-ventricular  opening  is  about  three- 
quarters  of  an  inch  lower  than  the  pulmonary  orifice. 
The  orifice  of  the  pulmonary  artery  is  on  a  line  with  the 
space  between  the  junction  of  the  second  and  the  third 
costal  cartilages  with  the  sternum,  being  to  the  left  and 
close  to  that  bone. 

The  orifice  of  the  aorta  is  at  the  commencement  of  the 
ascending  portion  of  the  arch,  and  is  on  a  line  with  the 
junction  of  the  third  costal  cartilage  of  the  left  side  with 
the  sternum.  The  arch  attains  the  level  of  the  upper 
border  of  the  second  costal  cartilage  of  the  right  side  at 
its  junction  with  the  sternum.  (Note. — These  relations 
vary  slightly  in  the  works  of  some  authors,  but  those 
mentioned  above  will  be  found  correct  for  practical  pur- 
poses.) 

The  region  of  the  walls  of  the  thorax  may  be  conve- 
niently described  surgically,  as  sternal,  costal,  diaphrag- 
matic, and  spinal. 

The  sternal  region  consists  of  the  sternum  itself  and 
of  the  structures  which  immediately  cover  it — viz.,  in- 
tegument, subcutaneous  cellular  tissue,  aponeurosis  of 
pectoralis  major,  sterno-mastoid,  rectus  abdominis,  and 
occasionally  fibres  of  the  rectus  stern alis  muscles  ;  it  is 
surgically  of  importance,  as  being  the  seat  of  fractures, 
of  dislocations  of  the  clavicle  from  it,  of  necrosis  from 
various  causes  and  of  growth.  The  mechanism  of  the 
sterno-clavicular  articulation,  which  possesses  an  inter- 
articular  fibro-cartilage  and  two  synovia!  membranes, 
allows  of  motion  in  almost  all  directions,  and  largely 
assists  in  the  free  play  of  the  shoulder.  The  peculiarity 
in  the  construction  and  the  curved  form  of  the  clavicle, 

10 


110  SURGICAL    ANATOMY    OF 

serve  to  break  the  effect  of  shocks  or  blows  upon  the 
shoulder  or  upper  limb.  On  the  right  side  the  sterno- 
clavicular  articulation  is  immediately  in  front  of  the  in- 
nominate artery  and  subclavian  vein,  whilst  on  the  left 
it  is  in  relation  with  the  left  subclavian  vein  and  the 
interspace  between  the  left  common  carotid  and  subcla- 
vian arteries ;  the  interclavicular  space  lies  immediately 
in  front  of  the  trachea.  Posteriorly  and  below,  the 
sternum  is  covered  by  the  triangularis  sterni  muscles, 
and  laterally  is  in  relation  with  the  internal  mammary 
vessels.  The  sternum  is  liable  to  fractures,  and  disloca- 
tions from  it  of  the  clavicle — an  accident  which  may 
occur  in  any  direction  but  downwards,  owing  to  its  close 
relation  with  the  cartilage  of  the  first  rib. 

The  costal  region,  which  is  bounded  anteriorly  by  the 
sternum,  laterally  by  the  sides  of  the  bodies  of  the  ver- 
tebrae, and  inferiorly  by  the  diaphragm,  presents  several 
points  of  surgical  importance,  since  it  contains  the  mam- 
mary gland  and  the  intercostal  spaces.  It  is  covered  in 
anteriorly  and  posteriorly  above  by  structures  belonging 
to  the  region  of  the  upper  extremity,  in  front  by  the 
greater  and  lesser  pectoral  muscles  with  their  aponeuroses, 
and  behind  by  the  scapula  and  the  muscles  attached  to 
it,  and  between  the  external  borders  of  the  scapular  and 
pectoral  muscles,  the  ribs  and  the  humerus,  is  a  special 
region, — the  axilla. 

The  intercostal  spaces  vary  considerably  in  extent: 
thus  they  are  larger  during  inspiration;  the  most  re- 
markable variation  in  the  interspace  is  at  its  middle,  as 
during  expiration  the  ribs  occasionally  approximate  so 
closely  that  their  edges  are  in  absolute  contact.  The 
operation  of  paracentesis  thoracis  or  tapping  the  thorax, 
in  pleurisy,  emphysema,  or  the  pointing  of  an  hepatic 


THE    THORAX.  Ill 

abscess,  is  usually  performed  between  the  fifth  and  sixth 
ribs,  just  behind  their  middle,  and  never  behind  the 
angle,  because  of  the  size  of  the  intercostal  arteries  at 
this  point,  and  moreover  on  account  of  the  thickness  of 
the  layers  of  muscle. 

Some  prefer  a  point  situated  an  inch  or  more  below 
the  angle  of  the  scapula,  between  the  seventh  and  eighth, 
or  eighth  and  ninth  ribs,  the  instrument  being  passed 
just  above  the  upper  border  of  the  rib,  so  that  the  inter- 
costal vessels  may  be  avoided.  On  the  right  side,  it  is 
advised  to  puncture  through  an  interspace  higher,  on 
account  of  the  position  of  the  liver  and  diaphragm  on 
that  side. 

The  internal  mammary  artery  belongs  properly  to  the 
cavity  of  the  chest,  lying  on  the  left  side  in  the  anterior 
mediastinum,  whilst  on  the  right  it  is  so  overlapped  by 
the  lung  as  to  be  excluded  from  the  space.  It  is  best 
exposed  from  the  surface,  by  raising  the  cartilages  of  the 
ribs  and  the  sternum,  and  is  then  seen  lying  upon  the 
pleura  at  a  short  distance  from  the  margin  of  the  sternum. 
It  is  given  off  from  the  subclavian  opposite  the  verte- 
bral, and  passes  into  the  thorax  in  relation  with  the 
phrenic  nerve,  which  crosses  it  anteriorly  and  then  de- 
scends internal  to  it.  Two  veins,  which  usually  unite 
to  form  a  common  trunk,  accompany  it.  In  the  upper 
part  of  the  chest  it  is  covered  in  by  the  costal  cartilages 
and  internal  intercostals,  whilst  below  it  lies  between  the 
triangularis  sterni  and  the  pleura.  Its  chief  inoscula- 
ting branches  are  given  off  at  the  interval  between  the 
sixth  and  seventh  cartilages,  and  are  musculo-phremc 
and  superior  epigastric. 

Wounds  of  this  vessel,  especially  if  situated  where  it 
has  any  bulk,  i.  e..  between  the  first  and  seventh  rib,  are 


112  SURGICAL    ANATOMY    OF 

serious.  It  can  be  tied  easily  in  the  first  three  intercostal 
spaces,  by  making  an  oblique  incision  about  two  inches 
long  from  without  inwards,  and  at  about  three  or  four 
lines  from  the  border  of  the  sternum,  and  the  structures 
divided  in  reaching  it  are — integument,  cellular  tissue, 
origin  of  pectoralis  major,  internal  intercostal  muscle. 
Owing  to  its  free  anastomoses,  of  course  both  ends  of  the 
wounded  vessel  require  ligature.  The  close  neighbor- 
hood of  the  ribs  to  the  lungs  and  pleura,  liver  and 
diaphragm,  render  fractures  by  direct  violence  often  very 
serious  from  puncture  of  these  structures  by  the  frag- 
ments. In  indirect  violence  the  rib  is  broken,  as  a  rule, 
near  the  angle,  and  there,  save  danger  from  punctures, 
wounds  of  the  intercostal  arteries  are  rare;  these  vessels 
are  difficult  to  secure,  from  their  position. 

Each  intercostal  artery  is  accompanied  by  a  vein  and 
nerve,  the  nerve  being  superior  to  the  artery  in  the  upper 
intercostal  spaces,  but  below  after  the  fourth  or  sixth 
space. 

They  are  protected  from  pressure  whilst  the  intercos- 
tals  are  acting,  by  being  inclosed  in  tendinous  bands, 
which  are  attached  to  the  ribs. 

Mamma. — The  breast  is  situated  in  front  of  the  pec- 
toralis major,  towards  the  lateral  aspect  of  the  region 
of  the  chest,  and  corresponds  to  the  interval  between  the 
third  and  seventh  ribs  (the  male  nipple  lies  on  the  fourth 
rib).  It  consists  of  gland  and  fibrous  tissues  arranged 
in  lobes;  these  are  very  numerous,  the  septa  between 
them  being  filled  up  by  fat.  Each  lobe  is  again  divisi- 
ble into  lobules,  which  are  connected  by  areolar  tissue, 
bloodvessels,  and  ducts.  The  lobules  open  into  the 
lactiferous  ducts,  which  uniting  form  larger  ones,  termi- 
nating in  an  excretory  duct,  and  are  generally  from  fif- 


THE    THORAX.  113 

teen  to  twenty  in  number;  these  converge  towards  the 
areola,  and  beneath  the  nipple  become  dilated  into  si- 
nuses, before  perforating  its  summit  by  separate  orifices. 
The  mammary  gland  is  separated  from  the  pectoralis 
major  and  minor,  the  serratus  magnus,  and  its  sheath  by 
a  layer  of  cellular  tissue  which  allows  of  the  free  move- 
ment of  the  gland  over  it, — an  important  point  in  the 
diagnosis  of  breast  tumors. 

The  breast  is  freely  supplied  with  vessels,  the  arteries 
being  derived  from  the  internal  mammary,  the  long 
thoracic  from  the  axillary,  and  the  intercostals ;  the 
veins  are  both  superficial  and  deep :  the  superficial  are 
seen  beneath  the  subcutaneous  cellular  tissue,  and  are 
very  much  distended  during  pregnancy,  whilst  the  deeper 
ones  follow  the  course  generally  of  the  arteries.  An 
anastomotic  circle  of  veins  is  seen  around  the  base  of 
the  nipple.  The  lymphatics  are  also  arranged  as  super- 
ficial and  deep:  the  former  are  immediately  beneath  the 
integument  and  pass  into  the  axillary  glands ;  the  latter 
set  accompany  the  galactiferous  tubes,  and  pass  into  the 
cellular  tissue  beneath  the  gland,  also  to  join  the  glands 
in  the  axilla  and  the  intrathoracic  ganglia.  The  nerves 
are  derived  from  the  brachial  and  cervical  plexuses  and 
from  the  intercostals. 

The  breast  is  the  seat  of  many  forms  of  tumors  which 
necessitate  its  removal,  and  its  great  vascularity  gives 
rise  to  severe  hemorrhage  during  such  operations;  it  is 
advisable,  therefore,  in  such  cases  to  make  the  inferior 
incision  first,  to  avoid,  if  possible,  any  complication, 
owing  to  the  parts  being  obscured  by  blood.  Mammary 
abscesses  ought  to  be  opened  vertically  (to  avoid  "  pocket- 
ing "  and  the  formation  of  sinuses),  freely  and  deeply, 
to  insure  the  exit  of  all  matter.  Moreover,  these  in- 


114  SURGICAL    ANATOMY    OF 

cisions  should,  if  possible,  be  made  parallel  to  the  course 
of  the  galactiferous  ducts,  if  near  the  nipple,  in  order  to 
avoid  cutting  across  them.  Guided  by  the  fascial  en- 
velope, collections  of  matter  connected  with  the  mam- 
mary gland  will  occasionally  point,  and  require  opening 
at  the  anterior  border  of  the  axilla. 

The  diaphragmatic  region,  or  floor  of  thorax,  is  formed 
by  the  diaphragm,  which  constitutes  the  septum  between 
the  thoracic  and  abdominal  viscera,  and  is  the  muscle 
of  normal  respiration.  Its  height,  or  the  amount  of 
encroachment  upon  the  thorax  during  ordinary  respi- 
ration, depends  in  some  measure  upon  the  amount  of 
distension  and  the  size  of  those  abdominal  viscera  in 
immediate  relation  with  it — viz.,  the  stomach,  intes- 
tines, and  the  liver.  During  normal  expiration  the 
right  arch  ascends  to  the  level  of  the  fifth  rib.  Forced 
expiration  brings  the  right  arch  of  the  muscle — that 
above  the  liver — to  a  level  with  the  fourth  costal  car- 
tilage in  front,  with  the  fifth,  sixth,  and  seventh  ribs 
at  the  side,  and  with  the  eighth  rib  behind.  The 
left  arch  is  lower  than  the  right  by  two  ribs.  During 
forced  inspiration  the  muscle  descends  to  the  level  of  a 
line  extending  from  the  ensiform  cartilage  to  the  tenth 
rib. 

The  under  surface  of  the  diaphragm  is  perforated  by 
three  large  foramina:  (1)  The  aortic,  situate  between 
the  pillars  of  the  muscle  and  spinal  column,  transmits 
the  aorta,  the  thoracic  duct,  and  the  vena  azygos  major. 
(2)  The  caval,  quadrilateral  in  shape  and  incapable  of 
constriction,  transmits  the  inferior  vena  cava.  (3)  The 
oasophageal,  elliptiform  in  shape  and  capable  of  con- 
striction, transmits  the  oesophagus,  also  the  vagi  nerves, 


THE    THORAX.  115 

the  left  being  in  front.  On  either  side  of  the  attach- 
ment to  the  xiphoid  cartilage  is  a  space  where  the  mus- 
cular tissue  is  wanting,  so  that  between  the  abdominal 
cavity  and  that  of  the  anterior  mediastinum  there  is  a 
communication,  filled  in  by  a  little  cellular  tissue, 
through  which  pass  some  lymphatics  from  the  liver, 
and  occasionally  diaphragmatic  hernia.  Collections  of 
pus  forming  in  the  thoracic  cavity  may  find  their  way 
through  these  spaces ;  moreover,  as  the  diaphragm  sepa- 
rates the  right  lung  from  the  liver,  abscesses  forming  in 
this  latter  viscus  may  either  be  discharged  by  the  bron- 
chi or  into  the  thoracic  cavity. 

Penetrating  wounds  of  the  diaphragm  are  serious, 
partly  on  account  of  hemorrhage,  and  from  the  fact  of 
viscera,  both  of  the  thoracic  and  abdominal  cavities, 
being  implicated ;  and  partly  on  account  of  the  intimate 
connection  with  it  of  large  serous  cavities,  the  pleurae, 
the  peritoneum,  and  the  pericardium. 

Occasionally  paralysis  of  the  diaphragm  occurs  with 
ascites,  or  may  be  owing  to  a  wound  in  the  neck  or  spi- 
nal column,  implicating  the  phrenic  nerve. 

An  approximation  of  the  course  taken  by  a  bullet  or 
a  weapon  penetrating  the  walls  of  the  thorax  from  its 
anterior  or  lateral  aspects,  may  be  gathered  from  the 
following  facts :  That  the  heart  would  be  reached  by  a 
wound  traversing  the  chest  at  right  angles,  above  the 
sixth  rib,  and  that  its  apex  lies  about  an  inch  and  a 
half  from  the  surface.  Wounds  in  the  mesial  line 
would  involve  the  heart  and  great  vessels,  whilst  more 
laterally  they  would  implicate  the  lungs;  the  position 
of  the  trunk  and  branches  of  the  internal  mammary 
render  penetrating  wounds  of  the  inferior  intercostal 
spaces  near  the  sternum  very  serious. 


116  SURGICAL    ANATOMY    OF 

A  wound  penetrating  the  sternum,  on  a  line  with  the 
nipple,  and  striking  upon  the  vertebra  at  right  angles 
with  the  axis  of  the  body,  would  traverse  three  cavities 
of  the  heart,  two  ventricles,  and  the  left  auricle. 

If  an  instrument  traversed  the  lower  intercostal  spaces 
during  inspiration,  it  would  wound  the  base  of  the  lung, 
the  diaphragm,  and  corresponding  abdominal  viscera, 
but  during  expiration  would  avoid  the  lung. 

Spinal  Region  of  Thorax. — The  posterior  wall  of  the 
thorax  is  formed  by  the  dorsal  spine  and  its  coverings, 
and  is  represented  by  a  region  bounded  superiorly  by 
the  first,  and  inferiorly  by  the  last  dorsal  vertebra,  and 
laterally  by  the  angles  of  the  ribs. 

The  integument  is  very  thick  and  dense,  and  con- 
tains a  quantity  of  sebaceous  follicles ;  the  subcutaneous 
cellular  tissue  is  intimately  united  to  the  spinous  pro- 
cesses of  the  dorsal  vertebra  (which  can  be  plainly  felt 
throughout  the  region),  thus  preventing  fluid  infiltrat- 
ing or  pus  appearing  superficially,  except  along  the 
sides  of  these  processes.  The  dorsal  aponeurosis  in- 
vests the  anterior  and  posterior  surfaces  of  the  trapezius 
and  latissimus  dorsi,  uniting  superiorly  with  the  cervi- 
cal, and  inferiorly  with  the  lumbar  aponeurosis,  split- 
ting to  inclose  the  serrati  postici ;  it  is  attached  to  the 
spinous  processes  of  the  dorsal  vertebrae  and  tubercles 
of  the  ribs,  inclosing  all  the  muscles  of  the  back,  and 
separating  the  superficial  from  the  deep  layer.  The 
first  layer  of  muscles  consists  of  the  lower  part  of  the 
trapezius  and  the  latissimus  dorsi,  the  former  overlap- 
ping the  latter.  Beneath  these  muscles  lie  the  rhom- 
boidei  and  serrati  postici.  The  deep  layer  consists  of 
the  sacro-lumbalis  internally  with  its  necessary  muscles, 


THE    THORAX.  117 

and  the  longissimus  dorsi  externally  also  with  its  acces- 
sory muscles ;  between  them  superiorly,  the  lower  por- 
tions of  the  splenius  colli,  complexus,  and  transversalis 
colli ;  deepest  of  all,  the  transverso-spinales  and  levatores 
costarum. 

Abscesses  connected  with  caries  of  the  transverse  pro- 
cesses, or  laminae  of  the  dorsal  vertebrae,  gravitate  into 
the  inferior  portion  of  the  region,  and  often  extend  to 
the  sides  of  the  ribs  or  into  the  axilla,  instead  of  becom- 
ing superficial,  on  account  of  the  strong  fascial  lamina 
between  the  superficial  and  deep  muscles. 

A  small  triangular  space  uncovered  by  muscle  exists 
at  the  point  where  the  trapezius  and  latissimus  dorsi 
diverge.  The  space  is  bounded  by  the  two  muscles  just 
named  towards  the  spine,  whilst  externally  it  is  com- 
pleted by  the  inferior  angle  of  the  scapula.  From  the 
fact  of  its  being  uncovered  by  muscle  it  is  available  for 
auscultation. 

The  vessels  met  with  are  dorsal  branches  from  the  in- 
tercostals  and  the  posterior  scapular,  and  the  nerves  are 
the  dorsal  branches  of  the  spinal,  with  some  few  branches 
from  the  cervical  plexus  and  spinal  accessory. 

With  regard  to  the  skeleton  of  this  region,  the  ar- 
rangement of  the  dorsal  vertebrae  renders  their  disloca- 
tion extremely  difficult,  and  when  it  does  occur  it  would 
seem  to  be  invariably  associated  with  fracture  of  some 
portion  of  the  spinal  column ;  the  spinous  processes  from 
their  position  are  often  fractured. 

The  dorsal  spine  is  very  often  the  seat  of  caries  of  the 
bodies  of  the  vertebrae,  or  disease  of  the  intervertebral 
substances,  inducing  angular  curvature  and  paralysis  of 
the  lower  limbs  from  pressure  on  the  cord.  "When  the 


118  SURGICAL    ANATOMY    OF 

disease  depends  upon  caries  of  the  bodies  of  the  vertebrae 
and  abscesses  form,  the  course  taken  by  the  pus  will  de- 
pend upon  the  part  of  the  spine  which  is  the  seat  of  dis- 
ease ;  and  it  generally  escapes  beneath  the  pillars  of  the 
diaphragm,  and  passes  beneath  the  fascia,  along  the  side 
of  the  aorta  and  iliac  arteries,  pointing  in  the  abdominal 
parietes  above  Poupart's  ligament.  If  the  abscess  de- 
pends upon  disease  of  the  lower  dorsal  vertebrae,  the  pus 
is  directed  forwards  by  the  sheath  of  the  psoas  muscle, 
and  points  below  Poupart's  ligament,  in  the  front  of  the 
thigh,  and  external  to  the  vessels.  The  pus  sometimes 
passes  backwards,  forming  dorsal  abscess.  If  it  gets  into 
the  subperitoneal  areolar  tissue  in  the  pelvis,  it  may  find 
its  way  into  the  perineum  by  the  side  of  the  rectum,  or 
pass  out  of  the  great  sciatic  notch,  and  appear  in  the 
region  of  the  great  trochanter.  From  the  continuity  and 
density  of  the  fascia  of  the  leg,  such  collections  of  matter 
may  make  their  way  into  the  popliteal  space,  or  even 
along  the  side  of  the  tendo-Achillis. 

Injuries  to  the  cord  in  the  dorsal  region,  if  below  the 
second  dorsal  vertebra,  do  not  affect  the  upper  extremity, 
but  the  respiration  is  greatly  affected,  owing  to  implica- 
tion of  the  nerves  supplying  the  intercostals  and  ab- 
dominal muscles ;  moreover,  there  is  paralysis  of  all  the 
parts  supplied  by  the  nerves  below  the  seat  of  injury. 

Region  of  the  Cavity  of  the  Thorax. 

As  this  region  can  scarcely  be  considered  as  within 
the  province  of  surgical  anatomy,  it  is  proposed  there- 
fore to  allude  to  it  as  shortly  as  possible.  Its  practical 
bearings  to  the  surgeon  seem  rather  to  be  upon  the  re- 


THE    THORAX.  119 

lations  of  the  contents  to  the  parietes,  which  have  been 
already  discussed,  both  as  far  as  physical  diagnosis  and 
injury  are  concerned;  and  considerations  with  respect  to 
aneurism  of  the  aorta  or  its  great  trunks  are  subjects 
rather  for  systematic  surgery.  Since  operative  proceed- 
ings on  the  oesophagus,  trachea,  or  great  vessels  are  insti- 
tuted in  the  neck,  the  chief  anatomical  bearings  of  these 
structures  will  be  found  described  in  the  chapter  on  the 
Surgical  Anatomy  of  the  Neck. 

The  cavity  of  the  thorax  is  most  conveniently  described 
for  reference  as  divisible  into  two  pleural  cavities,  sepa- 
rated in  the  lower  four-fifths  of  the  chest,  by  the  three 
mediastina,  and  in  the  upper  fifth  by  the  great  vessels 
springing  from  the  arch  of  the  aorta,  a  region  called  by 
Professor  Wood,  the  cervico-thoracic.  The  posterior 
wrall  of  this  division,  he  makes  the  three  upper  dorsal 
vertebrae  and  their  inter  vertebral  substances,  and  the  in- 
tervertebral  substance  between  the  third  and  fourth  the 
anterior — the  manubrium  sterni,  and  upper  fourth  or  fifth 
of  the  anterior  mediastinum ;  on  either  side  the  apices  of 
the  lungs  and  pleurae. 

The  anterior  mediastinum  is  bounded  as  follows  :  An- 
teriorly, by  the  sternum  and  left  costal  cartilages;  pos- 
teriorly, by  the  pericardium,  for  the  lower  three-fourths 
or  four-fifths,  and  for  the  rest,  by  the  cervico-thoracic 
region ;  laterally,  by  the  pleura.  The  middle  mediastinum 
contains  the  heart  and  ascending  portion  of  the  aorta 
and  arch,  phrenic  nerves  and  vessels,  and  is  limited 
behind  by  fibrous  pericardium  and  the  obliterated  ductus 
arteriosus.1  The  posterior  mediastinum  is  limited  above 

1  Vide  Professor  Wood,  F.R.S  ,  on  Kelations  of  Aorta  :  "  Journal 
of  Anatomy  and  Physiology,"  vol.  iii. 


120        SURGICAL    ANATOMY    OF    THE    THORAX. 

by  the  left  portion  of  the  arch,  below  by  the  lesser  mus- 
cle of  the  diaphragm  ;  laterally,  pleural  cavities,  root  of 
lungs,  and  ligamenta  lata  pulmonum. 

It  contains  the  bifurcation  of  the  trachea  and  bronchi, 
vagi,  oesophagus,  hinder  part  of  root  of  lung  and  recur- 
rent laryngeal  nerve  of  left  side,  descending  aorta,  azygos 
major  vein,  thoracic  duct,  and  great  splanchnic  nerves. 


SURGICAL    ANATOMY    OF    UPPER    EXTREMITY.      121 


CHAPTEK  IV. 

SUEGICAL  ANATOMY  OF  THE  UPPER  EXTREMITY. 
Region  of  the  Shoulder. 

Surface  Markings. — The  convexity  of  the  shoulder  is 
due  to  the  deltoid  muscle,  and  the  globular  head  of  the 
humerus.  The  bony  processes,  the  coracoid,  acromion, 
spine  of  scapula,  globular  head  of  humerus,  and  the  en- 
tire extent  of  the  clavicle,  can  be  readily  felt,  and  their 
exact  relation  with  regard  to  each  other  should  be  noticed 
and  compared,  their  respective  bearings  with  the  other 
bony  prominences  of  the  upper  extremity  carefully  studied 
both  at  rest  and  in  action.  The  precise  relations  of  these 
surface  marks  is  of  the  utmost  importance  in  the  diag- 
nosis of  fracture,  dislocation,  or  other  injury  to  the 
shoulder-joint,  and  moreover  they  serve  as  guides  for  the 
direction  of  the  knife  in  amputations  or  excisions.  When 
the  arm  hangs  along  the  side  with  the  palm  turned  for- 
wards, the  acromion,  epicondyle,  and  styloid  process  of 
radius  externally,  and  internally,  the  head  of  humerus, 
epitrochlea,  and  styloid  process  of  ulna,  correspond  ex- 
actly, and  their  mutual  relations  are  to  be  noted  in  every 
position  of  the  joint. 

Anterior  and  Lateral  Aspects'  of  the  Shoulder :  Surface 
Markings. — Anteriorly,  immediately  below  the  clavicle, 
is  a  fossa  in  which  the  pulsations  of  the  first  part  of  the 


122  SURGICAL    ANATOMY    OP 

axillary  artery  can  be  felt,  and  which  hollow  may  be 
obliterated  by  the  presence  of  axillary  tumors  or  disloca- 
tion of  the  humerus  forwards. 

Externally,  the  roundness  of  the  shoulder  is  formed 
by  the  deltoid  muscle,  beneath  which,  and  below  the 
overhanging  process  of  the  acromion,  can  be  felt  the 
globular  head  of  the  humerus.  This  portion  of  the 
bone  is  sometimes  very  large  in  proportion  to  the  artic- 
ulation, and  might  be  mistaken  for  a  displacement.  In 
any  dislocation,  however,  the  rotundity  of  the  shoulder 
gives  place  to  a  characteristic  flattening;  besides  impair- 
ment of  the  movements  of  the  joint.  Along  the  anterior 
border  of  the  deltoid  is  a  groove  between  it  and  the 
upper  fibres  of  the  pectoralis  major,  in  which  lie  the 
cephalic  vein  and  a  branch  of  the  acromio-thoracic 
artery.  The  skin  of  this  region  is  very  thick,  and 
glides  easily  over  the  underlying  tissues,  owing  to  the 
presence  of  bursse,  which  are  in  some  individuals  more 
or  less  developed,  according  to  the  use  made  of  the 
shoulder  by  their  occupation  or  work — thus,  by  carrying 
a  ladder  or  a  hod  of  mortar,  &c. 

To  the  upper  border  of  the  clavicle  are  seen  attached, 
along  its  sternal  portion,  the  outer  fibres  of  the  sterno- 
cleido-mastoid,  and  along  its  acromial  portion  the  tra- 
pezius. 

Below  are  the  attachments  of  the  pectoralis  major 
internally,  and  externally  the  deltoid.  The  clavicle  can 
be  felt  in  its  whole  extent,  owing  to  its  subcutaneous 
position,  and  from  being  so  exposed  is  liable  to  fracture. 
Again,  its  structure,  its  curves,  which  intensify  the 
shocks  of  indirect  violence,  and  the  want  of  support 
posteriorly,  all  contribute  towards  the  frequency  of  the 
accident. 


THE    UPPER    EXTREMITY.  123 

If  this  fracture  takes  place  at  its  centre,  the  displace- 
ment of  the  outer  fragment  downwards,  forwards,  and 
inwards,  is  due  to  the  weight  of  the  arm,  and  if  put  in 
action,  to  the  deltoid,  pectoralis  major,  and  subclavius. 
The  inner  fragment  is  occasionally  tilted  upwards,  but 
only  when  the  clavicular  fibres  of  the  sterno-cleido- 
mastoid  are  in  action,  as  in  rotation  of  the  neck,  the 
strong  ligamentous  attachment  to  the  rib  (costo-clavic- 
ular),  and  perhaps  the  clavicular  fibres  of  the  pectoralis 
major,  retaining  it  in  place.  The  slightness  of  the  dis- 
placement, on  fracture  of  the  acromial  and  sternal  ex- 
tremities, is  also  due  to  their  strong  ligamentous  attach- 
ment. The  clavicle  is  separated  from  the  upper  part  of 
the  axilla  and  its  contents  by  the  subclavius  muscle 
and  its  aponeurosis ;  behind  its  sternal  extremity  is  the 
junction  of  the  internal  jugular  vein  and  subclavian  vein 
running  closely  along  it ;  behind  its  upper  border  are 
the  supra-scapular  vessels,  which  are  liable  to  be  injured 
in  fracture  of  the  bone  or  operations  upon  it. 

External  Aspect  of  the  Shoulder. — The  deltoid  muscle 
forms  the  external  boundary  of  the  region  of  the  shoulder. 
The  subcutaneous  tissue  contains  the  terminal  twigs  of 
the  acromial  branches  of  the  descending  clavicular 
nerves,  and  of  the  cutaneous  branches  of  the  circumflex 
nerve  and  artery.  The  aponeurosis  of  the  deltoid  com- 
pletely covers  the  muscle,  and  is  continuous  with  that  of 
the  upper  arm  and  axilla,  sending  down  septa  between 
the  bundles  of  the  muscular  fibres,  and  passing  beneath 
it,  is  continuous  with  the  deep  fascia.  The  deltoid  itself, 
arising  from  the  outer  half  of  the  clavicle  and  the  lower 
border  of  the  spine  of  the  scapula,  after  the  convergence 
and  interlacement  of  its  fibres,  is  inserted  into  the  rough- 
ened surface  on  the  outer  aspect  of  the  humerus. 


124 


SURGICAL    ANATOMY    OF 


Parts  beneath  the  Deltoid. — Immediately  beneath  this 
muscle  is  a  large  bursa,  often  multilocular,  which  lies 
between  it  and  the  convex  head  of  the  humerus  and  the 
acromion  process ;  the  insertions  of  the  supra-  and  infra- 
spinatus  and  teres  minor  muscles  into  the  greater  tu- 


\Ai-W 


A.  Axillary  artery,  B.  Axillary  vein.  c.  Costc-soracoid  membrane.  D.  Cor- 
acoid  process.  E.  Coraco-acromial  ligament.  F.  Deltoid  cut  and  pulled  back. 
G.  Pectoralis  minor.  H.  Long  head  of  biceps,  i.  Short  head  of  biceps  and 
coraco-brachialis.  K.  Circumflex  vessels  and  nerve.  L.  Head  of  humerus  seen 
through  capsule,  upon  which  is  a  portion  of  the  bursa  between  it  and  the  del- 
toid. M.  Posterior  portion  of  this  bursa  between  the  deltoid  and  scapular  mus- 
cles. N.  Brachialis  anticus.  o.  Triceps.  (Altered  from  ANGER.) 

berosity,  and  passing  round  the  surgical  neck,  the  pos- 
terior circumflex  vessels  and  circumflex  nerve;  the 
bicipital  groove,  in  which  lies  the  long  head  of  the  bi- 
ceps and  the  anterior  circumflex  artery ;  the  coracoid 


THE    UPPER    EXTREMITY.  125 

process,  with  the  short  head  of  the  biceps  and  coraco- 
brachialis  attached  to  it,  a  quantity  of  loose  cellular 
tissue,  and  the  capsular  ligament.  Severe  blows  upon 
the  shoulder  frequently  cause  effusion  into  the  bursa 
above  named,  and  render  diagnosis  of  extreme  difficulty, 
and  suppuration  in  its  cavity  may  be  mistaken  for  dis- 
ease of  the  articulation.  In  the  case  of  effusion  of  blood 
into  the  cavity,  the  posterior  border  of  the  axilla  will 
become  discolored  a  few  days  after  the  injury. 

Posterior  Aspect  of  the  Shoulder :  Surface  Markings. — 
The  spine  of  the  scapula  is  seen  directly  beneath  the 
skin,  as  a  furrow  in  muscular  persons,  and  as  a  prom- 
inent ridge  in  emaciated  subjects,  terminating  in  its 
broad  acrornion  process,  which  overhangs  the  articula- 
tion. Above  and  below  the  spine  are  the  supra-  and 
infra-spinous  fossae,  filled  in  by  muscle,  the  superior 
fuller  than  the  inferior,  owing  to  the  attachment  of  the 
trapezius  along  the  upper  border  of  the  spine.  The 
inferior  angle  of  the  scapula  is  just  beneath  the  surface, 
having  sometimes  fibres  of  the  latissimus  dorsi  attached 
to  it,  which  muscle,  as  it  sweeps  forward  towards  the 
arm,  forms  the  posterior  border  of  the  axilla ;  occasion- 
ally the  scapula  becomes  dislocated  over  the  upper  edge 
of  this  muscle,  or  rather  the  muscle  slips  beneath  the 
scapula. 

The  supra-spinous  fossae  contains  the  supra-spinatus 
muscle,  between  which  and  the  bone  lie  the  supra- 
scapular  vessels  and  nerve,  the  nerve  passing  below  the 
supra-scapular  ligament  and  the  vessels  over  it ;  these 
vessels,  after  supplying  the  supra-spinatus  muscle  and 
the  nerve,  wind  round  the  root  of  the  acromion  into  the 
infra-spinous  fossa,  and  there  the  important  inosculation 
takes  place  between  the  dorsalis  scapulae  and  posterior 

11 


126  SURGICAL    ANATOMY    OF 

scapular,  which  becomes  greatly  developed  after  ligature 
of  the  subclavian  in  the  third  part  of  its  course,  playing 
a  chief  part  in  the  maintenance  of  the  collateral  circula- 
tion for  the  supply  of  the  arm.  In  front  of  the  scapula, 
between  it  and  the  ribs,  is  the  subscapularis,  a  multi- 
penniform  muscle,  the  full  development  of  which  gives 
such  an  appearance  of  depth  to  the  thorax  in  muscular 
persons.  Beneath  the  tendons  of  the  muscles  inserted 
into  the  greater  and  lesser  tuberosities,  are  large  bursse, 
occasionally  communicating  with  that  beneath  the  del- 
toid, and  with  the  synovial  membrane  of  the  shoulder- 
joint;  inflammation  or  suppuration  of  which  may  be 
mistaken  for  glandular  inflammation  or  for  axillary 
aneurism. 

Articulation  of  the  Shoulder-joint. — The  ellipsoidal  ar- 
ticular extremity  of  the  humerus  is  very  large  in  com- 
parison with  the  glenoid  cavity,  which  is  ovoid  in  shape, 
larger  below  than  above ;  and  it  is  surgically  of  impor- 
tance to  note  that,  not  only  are  the  articular  surfaces  of 
the  humerus  and  scapula  here  in  contact,  but  that  the 
head  of  the  bone  is  in  immediate  relation  with  the  arch 
formed  by  the  coracoid  and  acromion  processes  and  the 
coraco-acromial  ligaments — an  approximation  which  is 
due  to  the  action  of  the  deltoid,  in  atrophy  of  which 
muscle  there  is  a  considerable  interspace  between  these 
points.  The  capsule  of  the  joint  is  materially  strength- 
ened by  fibrous  expansion  from  the  tendons  of  those 
muscles  which  are  in  immediate  contact  with  the  articu- 
lation— viz.,  the  supra-  and  infra-spinati,  teres  minor, 
subscapularis,  and  long  head  of  biceps  and  triceps,  and 
by  bands  passing  from  the  coracoid  process.  The  syno- 
vial membrane  lining  the  capsule  is  prolonged  beneath 
the  subscapularis  muscle,  and  into  the  bicipital  groove. 


THE    UPPER    EXTREMITY.  127 

The  movements  of  which  the  humerus  is  capable  in 
the  glenoid  cavity  are  very  varied,  and,  with  a  view  to 
studying  the  action  of  the  muscles  in  dislocation  and 
fracture  of  this  bone,  and  in  their  diagnosis,  may  be 
classified  as  follows :  The  humerus  is  raised  by  the  del- 
toid, supra-spinatus,  long  head  of  biceps,  and  coraco- 
brachialis  ;  depressed  by  the  pectoralis  major,  latissimus 
dorsi,  teres  major,  and  subsc'apularis ;  brought  forward 
by  the  pectoralis  major,  anterior  fibres  of  deltoid,  coraco- 

FlG.  20. 


Diagrammatic  section  through  right  shoulder-joint,  showing  structures  in  con- 
tact with  it.  1.  Clavicle.  2.  Acromion.  3.  Supra-spinatus.  4.  Trapezius.  5. 
Infra-spinatus.  6.  Teres  minor.  7.  Teres  major.  8.  Latissimus  dorsi.  9.  Coraco- 
brachialis  and  short  head  of  biceps.  10.  Tendon  of  subscapularis  blended  with 
the  capsular  ligament.  11.  Pectoralis  major.  12.  Deltoid.  13.  Axillary  vessels 
and  nerves. 

brachialis,  and  short  head  of  biceps ;  drawn  backwards 
by  the  latissimus  dorsi,  teres  major,  long  head  of  triceps, 
posterior  fibres  of  deltoid,  supra-spinatus,  and  teres 
minor;  rotated  inwards  by  subscapularis,  teres  major, 
latissimus  dorsi,  pectoralis  major,  and  anterior  fibres  of 
deltoid ;  rotated  outwards  by  the  infra-spinatus,  teres 
minor,  coraco-brachialis,  and  posterior  fibres  of  deltoid. 


128  SURGICAL    ANATOMY    OF 

The  great  power  of  all  these  muscles  upon  this  joint, 
which  owes  its  great  extent  of  motion  to  the  shallow 
glenoid  cavity  and  large  head  of  humerus,  and  the 
laxity  of  its  capsule,  favors  dislocation  under  certain  cir- 
cumstances ;  and  were  it  not  for  the  bony  arch  formed 
by  the  coracoid  and  acromion  processes,  and  the  liga- 
ment between  them,  the  long  head  of  the  biceps  passing 
through  the  capsule  over  the  head  of  the  bone  and  blend- 
ing with  the  glenoid  ligament,  and  the  mobility  of  the 
scapula,  such  accidents  would  be  still  more  frequent. 

The  anatomical  position  of  the  head  of  the  humerus 
with  regard  to  the  neighboring  bony  structures  after  its 
dislocation  may  be  generalized  thus, — subglenoid,  sub- 
clavicular ',  subcoracoid,  subspinous. 

In  the  condition  termed  subglenoid,  the  head  of  the 
humerus  rests  on  the  inferior  border  of  the  scapula, 
below  the  glenoid  cavity,  between  the  subscapularis  and 
long  head  of  triceps ;  and  the  peculiar  numbness  in  the 
hand  and  arm,  and  frequent  coldness  and  oedema  in  the 
limb,  are  due  to  pressure  upon  the  brachial  plexus  and 
axillary  vessels.  In  the  subclavicular  variety,  the  head 
of  the  bone  lies  below  the  clavicle,  internal  to  the  cora- 
coid process,  upon  the  second  and  third  ribs,  and  be- 
neath the  pectoral  muscles.  In  the  subcoracoid,  the 
head  of  the  bone  lies  deeply  in  the  upper  and  inner  part 
of  the  axilla,  below  the  coraco-brachialis  and  pectoralis 
muscles.  In  the  subspinous  form,  the  head  of  the  bone 
lies  behind  the  glenoid  cavity,  below  the  spine,  and  be- 
tween the  infra-spinatus  and  teres  minor  muscles.  These 
may  be  regarded  as  the  complete  forms,  which  are,  of 
course,  liable  to  modifications. 

That  portion  of  the  bone  belonging  to  the  region  of 
the  shoulder — that  is  to  say,  as  low  down  as  the  inser- 


THE    UPPER    EXTREMITY.  129 

tion  of  the  deltoid — is  liable  to  fracture  of  the  anatomi- 
cal neck,  which  is  intra-capsular,  and  to  fracture  of  the 
surgical  neck,  which  is  extra-capsular.  In  the  former 
there  is  little  or  no  displacement  due  to  muscular  action ; 
in  the  latter  case  the  upper  fragment  is  drawn  up  slightly 
by  the  supra-  and  infra-spinatus,  teres  minor,  and  sub- 
scapularis ;  the  lower  fragment  is  drawn  inwards  by  the 
pectoralis  major,  latissimus  dorsi,  and  teres  major, 
whilst  the  deltoid  draws  it  obliquely  from  the  side  of 
the  body. 

In  cases  of  fracture  of  the  anatomical  neck,  with  sep- 
aration, it  may  necrose,  owing  to  there  being  no  means 
of  vascular  supply  to  the  fragment,  and  if  not,  it  may 
be  inferred  that  impaction  has  occurred.  At  any  rate, 
whatever  amount  of  repair  does  take  place  is  due  to  the 
lower  portion  of  the  shaft  of  the  bone.  In  impacted 
fracture  the  axis  of  the  bone  is  obviously  altered,  and 
there  is  a  slight  cavity  beneath  the  acromion,  owing  to 
shortening.  The  upper  articular  extremity  unites  with 
the  shaft  at  about  the  twentieth  year. 

The  upper  epiphysis  is  sometimes  separated  in  infants, 
in  consequence  of  the  carelessness  of  nurses  in  lifting 
them  suddenly  up  by  the  arm,  giving  rise  to  most  se- 
rious mischief. 

The  landmarks  already  described  in  the  superficial 
examination  of  the  shoulder  are  of  the  greatest  impor- 
tance in  the  performance  of  the  operations  of  amputation 
at  the  shoulder-joint,  and  of  excision  of  the  head  of  the 
humerus.  A  great  number  of  methods  are  described  in 
works  on  surgery  for  the  accomplishment  of  the  disar- 
ticulation,  but  it  will  suffice  to  mention  two  only — viz., 
that  of  the  operation  by  lateral  flaps,  and  the  oval 
method,  but  only  as  far  as  anatomy  bears  upon  the 


130  SURGICAL    ANATOMY    OF 

surgical  processes.  In  practice,  the  accurate  knowledge 
of  the  anatomy  of  the  parts  alone  must  guide  the  sur- 
geon, as  it  is  impossible  to  lay  down  rules  for  an  ampu- 
tation to  meet  the  exigencies  of  every  case.  For  rapidity 
of  execution,  the  former  may  be  practiced,  and  it  is  based 
upon  the  following  anatomical  considerations.  It  is  de- 
sired to  direct  the  point  of  the  knife  in  such  a  manner 
that  it  may  most  readily  and  easily  transfix  the  structures 
above  the  joint  (and  in  skilful  hands  the  joint  as  well), 
cut  one  flap,  disarticulate,  and  expose  a  second  flap,  and 
so  leave  all  large  arterial  and  venous  trunks  for  division 
until  the  last  moment.  The  point  to  be  felt  for  from  the 
surface,  which  serves  as  a  guide  for  the  point  of  the 
knife  to  make  for,  is  a  spot  between  the  acromion  and 
coracoid  processes  and  below  the  coraco-acromial  ligament. 
Posteriorly,  and  below,  the  guide  for  the  entry  or  emer- 
gence of  the  knife,  is  the  posterior  margin  of  the  axilla, 
just  in  front  of  the  tendons  of  the  teres  major  and  la- 
tissimus  dorsi;  it  is  then  pushed  upward  and  forwards 
— the  elbow  being  moved  outwards  and  upwards,  in 
order  that  the  head  of  the  bone  may  be  as  low  down  in 
the  glenoid  cavity  as  possible — through  the  structures 
close  to  the  bone,  until  it  emerges  at  the  point  above  in- 
dicated, and  a  large  external  flap  cut;  the  joint  is  next 
opened,  and  the  attachments  of  the  muscles  around  it 
being  divided,  the  elbow  is  carried  in  front  of  the  chest, 
and  the  head  of  the  bone  pushed  backwards  to  put  the 
tendons  on  the  stretch ;  after  the  disarticulation  is  effect- 
ed, a  posterior  flap  of  about  the  same  length  is  to  be 
made,  in  which  lie  the  vessels  and  nerves. 

Contents  of  Flaps  after  Disarticulation  at  Shoulder-joint 
by  Transfixion. — The  external  flap  thus  fashioned  will 
contain, — integument,  the  posterior  fibres  of  the  deltoid, 


THE    AXILLA.  131 

circumflex  vessels  and  nerve,  tendons  of  latissimus  dorsi, 
teres  major,  and  teres  minor;  the  internal  flap, — the  sub- 
scapularis,  long  head  of  biceps,  coraco-brachialis,  an- 
terior fibres  of  deltoid,  pectoralis  major,  axillary  vessels 
and  nerves,  and  integuments. 

In  the  oval  method  the  articulation  is  exposed,  by 
making  an  incision  about  two  inches  long  down  to  the 
bone,  immediately  below  the  acromion  process,  and  a 
curved  incision  from  this  point  on  either  side,  each  in- 
closing a  semilunar  flap,  to  the  anterior  and  posterior 
folds  of  the  axilla.  Disarticulation  is  next  effected. 

The  most  anatomical  as  well  as  the  best  method  of  ex- 
cising the  head  of  the  bone,  is  by  exposing  it  by  a  ver- 
tical incision  extending  from  a  point  just  external  to  the 
tip  of  the  coracoid  process,  corresponding  to  the  position 
of  the  bicipital  groove;  an  incision  which  has  the  ad- 
vantage of  avoiding  the  circumflex  vessels  and  nerve. 
The  long  tendon  of  the  biceps  should  be  preserved,  if 
possible,  to  assist  in  the  movements  of  the  resulting 
false  joint. 


SUKGICAL  ANATOMY  OF  THE  AXILLA. 

Surface  Markings  and  External  Form. — When  the  arm 
lies  against  the  wall  of  the  chest  the  area  of  the  axillary 
space  becomes  confined,  and  for  anatomical  considerations 
ceases  to  exist;  also  when  extended  beyond  a  right 
angle,  the  head  of  the  humerus  projects  into  the  space 
and  obliterates  its  fold.  But  when  the  arm  is  raised  to 
about  an  angle  of  45°,  and  the  muscles  contract,  the 
depth  of  the  fold  of  the  axilla  is  most  marked. 

The  boundaries  of  the  axilla,  which  are  seen  beneath 
the  skin,  are, — anteriorly,  the  lower  margin  of  the  pec- 


132         SURGICAL    ANATOMY    OF    THE    AXILLA. 

toralis  major  muscle,  rounded  and  muscular,  but  becom- 
ing short  and  tendinous  as  it  approaches  the  humerus ; 
posteriorly,  the  lower  edge  of  the  latissimus  dorsi  muscle ; 
internally,  the  chest- wall;  externally,  the  arm.  The 
axillary  artery  is  readily  felt  along  the  external  bound- 
ary, and  may  be  here  compressed  against  the  bone  as  it 
lies  in  the  third  part  of  its  course,  and  it  will  be  ob- 
served that  this  vessel  follows  the  course  of  the  arm  in 
whatever  position  it  takes.  The  base  is  formed  by  the 
integument,  which  is  fully  provided  with  hair-bulbs  and 
sebaceous  follicles. 

As  the  axilla  would,  in  most  cases,  be  attacked  surgi- 
cally from  below,  that  is,  from  its  base  towards  its  apex, 
it  will  be  found  to  be  advisable  to  describe  its  relations 
and  contents  as  they  would  be  met  with  in  this  direc- 
tion. 

Dissection. — The  arm  is  to  be  raised  to  a  right  angle 
with  the  trunk,  and  the  palm  of  the  hand  turned  for- 
ward. The  integument  being  removed  along  the  boun- 
daries of  the  base,  the  subcutaneous  cellular  tissue  is  first 
met  with,  containing  a  good  deal  of  reddish  fat  in  its 
meshes;  next,  an  aponeurosis,  which  is  continuous  in 
front  with  the  sheath  of  the  pectoralis  major;  behind 
with  that  of  the  latissimus  dorsi;  externally  with  the 
brachial  aponeurosis,  and  internally  with  that  covering 
the  serratus  magnus.  On  removing  this  aponeurosis  the 
axillary  space  is  opened ;  a  large  quantity  of  loose  fat 
and  cellular  tissue  and  a  quantity  of  lymphatic  glands 
are  seen  filling  up  the  interspace  between  the  thorax  and 
the  arm. 

Lying  in  this  cellular  tissue,  and  bridging  across  from 
the  arm  to  the  chest,  will  be  seen  a  good  many  nerves, 
the  intercosto-humeral,  which,  in  some  subjects,  form 


SURGICAL    ANATOMY    OF    THE    AXILLA.        133 

almost  a  plexus,  supplying  the  skin  of  the  base  of  the 
axilla;  together  with  some  branches  of  the  axillary 
artery,  the  long  thoracic  and  its  veins  passing  downwards 
and  forwards  towards  the  anterior  inferior  aspect  of  the 
space,  besides  a  considerable  number  of  branches  to  the 
glands  (alar  thoracic).  On  removing  this  cellular  tissue 
the  walls  of  the  axillary  space  can  be  made  out. 

The  internal  wall,  slightly  convex,  is  formed  by  the 
first  four  ribs  and  their  intercostal  muscles,  and  the  first 
five  serrations  of  the  serratus  magnus,  upon  which  lie 
the  posterior  thoracic  nerve,  the  superior  thoracic,  and 
long  thoracic  branches  of  the  axillary  artery,  with  their 
corresponding  veins.  The  external  wall,  formed  by  the 
scapulo-humeral  region,  is  the  most  important,  as  on  it 
lie  the  great  vessels  and  nerves  in  their  fascial  envelope ; 
and  the  fact  of  the  close  adherence  of  these  structures  to 
this  wall  of  the  axilla  is  of  great  value  to  the  surgeon 
in  the  extirpation  of  tumors  or  the  opening  of  abscesses, 
which  fortunately  as  a  rule  lie  along  the  inner  wall.  On 
either  side  of  the  bicipital  groove  are  inserted  the  ten- 
dons of  the  pectoralis  major  and  teres  major,  the  latter 
being  internal,  and  a  little  anterior  and  external  is  the 
tendon  of  the  latissimus  dorsi.  Lying  in  this  groove 
and  inclosed  in  a  prolongation  of  the  synovial  mem- 
brane of  the  joint  is  the  long  head  of  the  biceps  itself; 
and  most  internally  are  seen  the  conjoined  fibres  of  the 
coraco-brachialis  and  short  head  of  biceps,  the  inner 
border  of  the  former  being  the  guide  to  the  vessel;  the 
insertion  of  the  tendon  of  the  subscapularis,  and  origin 
of  the  long  head  of  the  triceps.  Above  the  tendon  of 
the  teres  major  the  lower  portion  of  the  capsule  of  the 
joint  is  visible. 

The  anterior  wall  is  formed  by  the  pectoralis  major 
12 


134         SURGICAL    ANATOMY    OF    THE    AXILLA. 

and  minor  and  their  aponeuroses,  and  the  lower  border 
of  the  former  covered  by  the  integuments  constitutes  its 
anterior  inferior  margin.  In  the  female  this  margin  is 
hidden  by  the  mammary  gland,  which  overhangs  it. 
The  position  of  this  gland  is  not  influenced  by  the  move- 
ments of  the  shoulder  upon  the  trunk,  as  the  cellular 
membrane  between  it  and  the  anterior  layer  of  the  sheath 
of  the  pectoralis  major  permits  of  the  free  motion  of  the 
muscle  beneath  it;  but  in  the  case  of  scirrhus,  owing  to 
infiltration  of  the  tissues,  the  movements  of  the  pectoral 
are  made  with  great  pain  and  difficulty.  On  the  pos- 
terior surface  of  these  muscles  are  seen  the  acromio- 
thoracic  vessels  and  external  and  internal  anterior  tho- 
racic nerves. 

The  posterior  wall  is  formed  by  the  teres  major  and 
latissimus  dorsi  muscles  below,  and  by  the  subscapularis 
above  with  their  vascular  and  nervous  supply. 

The  apex  of  the  axilla  may  be  referred  to  the  coracoid 
process,  though  more  correctly  to  the  aperture  between 
the  clavicle,  upper  border  of  scapula,  and  first  rib,  with 
their  muscular  coverings.  The  cellular  tissue  of  the 
cavity  of  the  axilla,  becomes  continuous  with  that  of  the 
subclavian  region  at  the  apex  by  enveloping  the  vessels 
that  pass  through  this  interspace. 

The  axillary  artery,  axillary  vein,  and  brachial  plexus 
form  a  vasculo-nervous  cord,  bound  together  by  a  dense 
cellular  sheath  which  is  placed  on  the  outer  wall  of  the 
space,  and  lying  along  the  inner  border  of  the  coraco- 
brachialis  muscle ;  the  pulsations  of  the  artery  are  felt  at 
the  apex  (if  the  pectoralis  major  is  relaxed),  and  at  its 
lower  portion,  and  in  thin  persons,  the  cord  of  the  median 
nerve  is  usually  seen  stretched  over  it  when  the  arm  is 
raised  from  the  side.  The  course  of  this  vessel  is  indi- 


SURGICAL    ANATOMY    OF    THE    AXILLA.        135 

cated  by  a  line  passing  through  the  axilla,  drawn  from 
about  the  centre  of  the  clavicle  to  the  inner  border  of  the 
coraco-brachialis  muscle.  It  lies  in  an  envelope  of  ner- 
vous cords, — the  median,  musculo-spiral,  musculo-cuta- 
neous,  ulnar,  and  internal  cutaneous.  The  axillary  vein 
is  very  large,  and  lies  internal  to  and  a  little  in  front  of 
the  artery,  and  in  ligature  of  the  artery  it  is  seen  first, 
and  miust  be  drawn  to  one  side.  It  is  adherent  to  the 
cellular  tissue  and  by  fascial  attachment  to  the  coracoid 
process,  and  if  wounded  is  liable  to  gape  considerably, 
and  thus  admit  air,  an  accident  which  has  happened  in 
removing  axillary  tumors. 

The  branches  of  the  axillary  artery  are  usually  given 
off  in  the  following  order :  the  thoracica  suprema,  which 
runs  along  the  upper  part  of  the  inner  wall ;  the  acromio- 
thoracic,  sending  branches  to  its  anterior  wall ;  the  long 
thoracic,  lost  on  the  thorax  and  mammary  gland ;  the 
subscapular,  which  descends  obliquely  along  the  inferior 
border  of  the  subscapularis,  and  is  distributed  to  the 
muscles  of  the  posterior  wall,  one  large  branch  in  par- 
ticular, the  dorsalis  scapulce,  passing  to  the  dorsum  scap- 
ulae in  the  triangular  interval  between  the  two  teres 
muscles  and  long  head  of  triceps  ;  the  posterior  circumflex 
passes  through  the  quadrilateral  space  formed  by  the  two 
teres  muscles,  long  head  of  triceps,  and  humerus,  and 
winds  round  the  neck  of  the  humerus,  supplies  the  del- 
toid, and  is  accompanied  by  the  circumflex  nerve  and 
veins  ;  the  anterior  circumflex,  a  small  branch,  is  supplied 
to  the  articulation  beneath  the  coraco-brachialis  and  bi- 
ceps, and  inosculates  with  the  former. 

Thus,  if  the  vessel  be  normal,  the  acromio-thoracic, 
and  thoracica  suprema  are  given  off  above  the  pectoralis 
minor,  the  external  mammary  about  opposite  its  middle, 


136        SURGICAL    ANATOMY    OF    THE    AXILLA. 

and  the  dorsalis  scapulae  and  anterior  and  posterior  cir- 
cumflex at  the  lower  border  of  the  subscapularis  muscle. 

Besides  the  large  nervous  trunks,  branches  derived 
from  them  are  met  with  passing  to  the  muscles  covering 
the  several  walls  of  the  space.  Thus,  the  anterior  wall 
is  supplied  by  the  loop  formed  round  the  first  part  of 
the  artery  by  the  external  and  internal  anterior  thoracic 
nerves,  the  inner  wall  by  the  posterior  thoracic,.the  pos- 
terior wall  by  the  subscapular,  the  outer  by  the  circum- 
flex and  muscnlo-cutaneous. 

The  lymphatic  ganglia  are  very  numerous,  and  lie, 
some  along  the  course  of  the  vessels,  and  some  along  the 
lower  border  of  the  pectoralis  major.  These  ganglia  re- 
ceive the  lymphatics  of  the  upper  extremity,  back,  and 
posterior  part  of  neck,  the  lateral  lymphatics  of  the  trunk, 
those  of  the  epigastrium  and  anterior  part  of  thorax,  and 
mammary  region. 

In  order  to  gain  a  topographical  idea  of  the  position 
of  this  vessel,  in  the  first  part  of  its  course,  i.  e.,  between 
the  clavicle  and  the  upper  border  of  the  pectoralis  minor 
muscle,  it  is  best  exposed  from  the  front,  by  detaching 
the  clavicular  attachment  of  the  pectoralis  major  and 
turning  it  down,  when  it  will  be  found  lying  in  a  tri- 
angle (the  subdavicular\  which  is  bounded  above  by  the 
subclavius  muscle,  below  by  the  pectoralis  minor,  and 
internally  by  the  thorax.  Immediately  beneath  the  de- 
tached portion  of  the  pectoralis  major  is  a  dense  fascia 
(the  costo-coracoid  membrane),  a  prolongation  of  the  deep 
cervical,  passing  beneath  the  clavicle,  and  attached  to 
the  coracoid  process  and  upper  ribs,  enveloping  the  pec- 
toralis minor  and  binding  down  the  axillary  vessels  in 
a  sort  of  sheath.  From  the  lower  border  of  the  muscle 
this  aponeurosis  descends,  to  be  attached  to  that  covering 


SURGICAL    ANATOMY    OF    THE    AXILLA.         137 

in  the  pectoralis  major  and  that  forming  the  floor  of  the 
axillary  space.  It  assists  in  forming  the  fold  of  the 
axilla,  and  has  been  termed  the  "  suspensory  ligament." 
Perforating  this  membrane  are  seen  the  cephalic  vein, 
passing  into  the  subclavian,  the  acromio-thoracic  vessels, 
and  the  external  anterior  thoracic  nerve.  In  front  of 
the  vessel  in  this  part  of  its  course  lie  the  clavicular 
portion  of  pectoralis  major,  the  subclavius  muscle,  costo- 
coracoid  membrane,  and  cephalic  vein,  and  the  loop  from 
the  outer  and  inner  cords,  giving  off  the  external  and 
internal  anterior  thoracic  nerve ;  externally,  the  cords  of 
the  brachial  plexus ;  internally,  the  axillary  vein ;  pos- 
teriorly 9  the  first  intercostal  muscle,  second  serration  of 
serratus  magnus,  and  the  nerve  of  Bell. 

The  second  part  of  the  course  of  this  vessel  lies  beneath 
the  crossing  of  the  pectoralis  minor,  and  by  dividing 
the  remaining  portion  of  the  pectoralis  major  and  the 
pectoralis  minor,  the  whole  extent  of  the  vessel  will  be 
exposed. 

In  front  of  the  second  portion  of  the  vessel  lie  the 
pectorals  and  inner  head  of  median  nerve;  externally, 
the  external  cord  of  the  brachial  plexus ;  internally,  the 
axillary  vein  and  inner  cord  of  the  plexus ;  posteriorly, 
the  posterior  cord  of  the  plexus  and  the  subscapularis 
muscle,  separated  from  it  by  a  cellular  interval. 

The  third  portion  of  the  vessel  is  beyond  the  pecto- 
ralis minor,  and  between  it  and  the  lower  border  of  the 
pectoralis  major  by  which  it  is  covered.  In  front  of 
the  third  portion  of  its  course  lies  the  pectoralis  major; 
externally,  the  coraco-brachialis,  the  median,  and  mus- 
culo-cutaneous  nerves ;  internally,  the  ulnar  and  inter- 
nal cutaneous  nerves  and  axillary  vein ;  posteriorly,  the 
musculo-spiral  and  circumflex  nerves,  and  the  tendons 


138         SURGICAL    ANATOMY    OF    THE    AXILLA. 

of  the  latissimus  dorsi,  teres  major,  and  \subscapularis 
muscles. 

Ligature  of  the  Axillary  Artery. — The  axillary  artery 
may  be  tied  in  the  first  part  of  its  course  or  in  the  third. 

In  the  first  part  it  is  very  deep  and  difficult  of  access, 
but  it  may  be  reached,  either  by  separating  the  fibres  of 
the  pectoralis  major  and  deltoid,  or  by  means  of  a  semi- 
lunar  incision  through  the  integument,  extending  from 
a  little  external  to  the  sterno-clavicular  joint  towards  the 
coracoid  process,  taking  care  to  avoid  the  cephalic  vein ; 
next  the  clavicular  fibres  of  the  pectoralis  major  must 
be  divided,  the  arm  adducted,  and  the  pectoralis  minor 
drawn  down.  The  costo-coracoid  membrane,  which  is 
next  seen  on  the  stretch,  must  be  opened,  the  cords  of 
the  plexus  drawn  outwards,  and  the  axillary  vein  in- 
wards, when  the  ligature  can  be  passed  from  within  out- 
wards. 

This  operation  is  very  difficult  and  dangerous,  from 
the  close  relation  of  the  axillary  and  cephalic  veins,  and 
the  acromio-thoracic  vessels. 

In  the  third  part  the  vessel  is  easily  reached. 

The  arm  is  to  be  extended  and  supinated,  in  order  to 
throw  out  the  fold  of  the  coraco-brachialis  muscle,  the 
inner  border  of  which  is  the  guide  to  the  artery,  and  an 
incision  of  about  three  inches  in  length  is  to  be  made 
through  the  integument,  rather  nearer  the  anterior  than 
the  posterior  fold  of  the  axilla,  the  deep  fascia  being 
scratched  through  and  the  basilic  or  axillary  vein 
avoided  ;  the  artery  is  seen  lying  crossed  by  the  median 
nerve,  and  having  the  axillary  vein  to  its  inner  side, 
and  sometimes  on  it ;  these  structures  must  be  carefully 
isolated,  and  the  needle  passed  from  within  outwards. 
Occasionally  the  vessel  divides  high  up  into  the  brach- 


SURGICAL    ANATOMY    OF    THE    AXILLA. 


139 


ial  and  radial,  thus  complicating  the  operation  of  liga- 
ture. Again,  after  division,  these  trunks  may  reunite 
by  cross  branches,  and  the  circulation  continue  as  freely 
as  before,  unless  a  ligature  be  applied  to  each. 


1.  Median  nerve.    2.  Axillary  artery.    3.  Internal  cutaneous  nerve.    4.  Axillary 
vein.    5.  Ulnar  nerve.    6.  Coraco-brachialis  muscle.    7.  Deltoid  muscle. 


Collateral  Circulation  after  Ligature  of  the  Axillary. — 
Ligature  of  the  axillary  artery  in  the  upper  part  of  the 
first  portion  of  its  course,  above  the  giving  off  of  the 
acromial  thoracic,  may  be  regarded  as  equivalent  to 
ligature  of  the  subclavian  in  the  third  part  of  its  course 
(vide  Ligature  of  Subclavian).  If  the  vessel  be  tied 
below  this  point,  the  subscapular  inosculating  with  the 
suprascapular  and  posterior  scapular,  and  the  long  tho- 
racic with  the  internal,  mammary  and  intercostals,  are 
called  upon  to  restore  the  circulation.  If  the  ligature 
be  applied  below  the  giving  off  of  the  subscapular, 
the  posterior  circumflex,  anastomosing  with  the  supra- 


140  SURGICAL    ANATOMY    OF 

scapular  and  acromio-thoracic,  and  the  subscapular  with 
the  superior  profunda,  form  the  chief  collateral  channels. 


SURGICAL  ANATOMY  OF  THE  BRACHIAL  REGION. 

Surface  Markings. — This  region  may  be  considered 
as  lying  between  a  line  drawn  round  the  lower  border 
of  the  axilla,  and  another  round  the  arm  just  above  the 
condyles  of  the  humerus.  Its  general  form  is  that  of  a 
cylinder,  flattened  internally  and  externally,  convex  in 
front,  owing  to  the  swell  of  the  biceps  muscle.  Along 
the  inner  aspect  of  the  biceps  is  a  well-marked  groove, 
extending  from  the  axilla  to  the  bend  of  the  elbow; 
whilst  a  shallow  groove  exists  also  on  its  outer  surface, 
becoming  lost  at  the  point  of  insertion  of  the  deltoid ; 
beneath  the  skin  is  seen  in  the  internal  groove  the 
basilic  vein,  and  external  to  the  biceps,  the  cephalic. 
The  posterior  surface  of  the  brachial  region  is  rounded 
at  about  its  middle,  where  the  greater  mass  of  the  tri- 
ceps muscle  lies,  and  below  this  point  its  flattened 
sharp-edged  tendon  forms  towards  its  insertion  into  the 
olecranon.  In  the  inner  groove  lies  the  brachial  artery, 
where  it  can  be  felt  or  seen  pulsating,  overlapped  by  the 
inner  border  of  the  biceps  at.  about  its  middle,  the  mus- 
cle forming  the  guide  to  it  throughout  its  course,  either 
for  its  deligatiori  or  compression.  The  surgical  consid- 
erations .  affecting  this  region  refer  chiefly  to  amputa- 
tion, ligature  of  its  vessel,  fractures,  and  the  removal  of 
tumors. 

On  removing  the  skin,  the  subcutaneous  cellular 
tissue,  divided  into  two  laminae  by  a  layer  of  fat,  is 
first  met  with,  and  it  is  in  this  structure  that  the  super- 
ficial nerves,  veins,  and  lymphatics  lie.  The  brachial 


THE    BRACHIAL    REGION.  141 

aponeurosis  completely  envelops  the  arm,  and  is  thickest 
at  the  back  and  sides ;  it  is  continuous  above  with  that 
covering  the  deltoid  and  subclavicular  region,  and  below 
with  that  covering  the  forearm,  and  sending  processes 
between  the  muscles  forms  septa,  which  are  attached  to 
the  humerus.  The  attachment  of  this  aponeurosis  is 
very  evident  laterally,  where  it  is  inserted  into  the 
condyles  and  condyloid  ridges  of  the  humerus,  dividing 
the  region  into  two  distinct  compartments,  an  anterior 
and  a  posterior.  The  anterior  contains,  successively, 
the  biceps,  immediately  beneath  which,  in  the  lower 
half  of  the  arm,  is  the  brachialis  anticus,  inclosing  at 
the  upper  part  of  its  origin,  the  insertion  of  the  deltoid, 
and  passing  downwards  to  its  own  insertion,  covers 
in  the  humerus  completely  between  the  lateral  margin 
of  the  anterior  and  posterior  compartments.  Behind, 
and  internal  to  the  biceps  above,  is  the  coraco-brachi- 
alis;  below  and  externally  are,  the  musculo-spiral  nerve, 
the  origins  of  the  supinator  longus  and  extensor  carpi 
radialis  longior. 

Lying  along  the  inner  border  of  the  biceps  is  the 
vasculo-nervous  cord,  formed  by  the  brachial  artery,  its 
veins,  and  the  median,  ulnar,  external,  and  internal 
cutaneous  nerves;  the  median  accompanies  the  artery 
throughout,  lying  first  outside  it,  then  upon  it,  and  lastly 
internal.  In  the  upper  third,  this  vasculo-nervous  cord 
lies  along  the  inner  border  of  the  coraco-brachialis,  having 
the  long  head  of  the  triceps  behind,  and  just  on  the 
humerus,  against  which  the  vessel  is  easily  compressed ; 
in  its  lower  two-thirds  it  lies  on  the  brachialis  anticus. 

The  posterior  aponeurotic  compartment  contains  the 
triceps,  which  covers  in  the  entire  posterior  surface  of 
the  humerus  and  the  musculo-spiral  nerve  before  it  passes 


142 


SURGICAL    ANATOMY    OF 


anteriorly,  as  it  lies  in  the  musculo-spiral  groove  with 
the  superior  profunda  vessels,  before  it  perforates  the 
septum  to  pass  into  the  anterior  compartment.  It  also 


FIG.  22. 


A  section  through  the  middle  of  the  right  upper  arm.  1.  Biceps.  2.  Cephalic 
vein.  3.  Brachial  vessels.  4.  Musculo-cutaneous  nerve.  5.  Median  nerve.  6. 
Brachialis  anticus.  7.  Ulnar  nerve.  8.  Musculo-spiral  nerve.  9.  Basilic  vein, 
with  internal  cutaneous  nerves.  10.  Superior  profunda  vessels.  11.  Inferior 
profunda  vessels.  12.  Triceps,  with  fibrous  intersection.  (HEATH.) 

contains  the  ulnar  nerve,  which  at  first  lies  in  the  an- 
terior compartment,  in  contact  with  the  brachial  artery 
above. 

A  correct  knowledge  of  the  relations  of  the  layers  of 
these  muscles,  their  aponeuroses,  and  the  course  taken 


THE    BRACHIAL    KEGION.  143 

by  the  main  vessel  and  its  branches,  determines  the  con- 
tents of  the  flaps  in  amputation  of  the  upper  arm. 

Relations  of  Bracliial  Artery  (above  bend  of  elbow). — 
Its  course  is  indicated  by  a  line  drawn  from  the  junction 
of  the  anterior  with  the  posterior  two-thirds  of  the  axilla, 
to  the  centre  of  the  bend  of  the  elbow.  It  is  accompanied 
by  venae  comites,  which  frequently  interlace  and  conceal 
the  vessel  when  cut  down  upon.  In  front  of  the  vessel 
is  the  integument  and  fasciae  and  the  median  nerve;  ex- 
ternally, median  nerve  (in  upper  half),  coraco-brachialis, 
and  biceps ;  internally,  internal  cutaneous  and  ulnar 
nerves,  and  in  lower  half  the  median  nerve ;  posteriorly, 
lie  the  brachialis  anticus,  coraco-brachialis,  musculo- 
spiral  nerve,  and  superior  profunda  vessels,  separating 
the  middle  and  long  heads  of  the  triceps. 

Ligature  in  the  upper  third  is  performed  by  making  an 
incision  about  two  inches  in  length  along  the  inner  bor- 
der of  the  coraco-brachialis  muscle ;  the  subcutaneous 
tissue  and  aponeurosis  are  to  be  divided,  taking  care  to 
avoid  the  basilic  vein ;  then  the  internal  cutaneous  and 
ulnar  nerves  will  be  found  on  the  inner  side  of  the  artery, 
the  median  externally,  and  a  number  of  venae  comites 
superficial  to,  and  on  each  side  of  it.  The  needle  should 
be  applied  from  within  outwards.  Occasionally  two  ves- 
sels are  found  lying  parallel  to  each  other,  or  placed  one 
over  the  other,  the  posterior  lying  very  deep,  the  result 
of  a  high  division  ;  under  such  circumstances  it  is  obvi- 
ous that  it  must  be  determined  by  pressure  whether  one 
or  both  communicate  with  the  aneurism  or  wound. 

In  the  middle  third  the  vessel  is  not  so  easy  to  tie  as 
might  be  imagined  from  its  superficial  position ;  it  is 
beneath  a  very  dense  part  of  the  fascia,  often  overlapped 
by  the  biceps,  and  very  movable  beneath  the  integument. 


14:4  SURGICAL    ANATOMY    OF 

It  is  reached  by  an  incision  along  the  inner  border  of 
this  muscle,  the  forearm  being  slightly  flexed  so  as  to 
relax  the  biceps.  The  median  nerve  is  usually  first  met 
with,  crossing  the  vessel ;  this  should  be  drawn  inwards 
and  the  biceps  outwards,  and  the  venae  comites  carefully 
separated  from  the  trunk  before  a  ligature  is  applied.  In 
this  instance,  as  in  several  others,  it  is  advisable  to  make 
the  incision  slightly  oblique  to  the  real  course  of  the 
vessel,  as  room  is  gained,  and  also  a  better  view  of  any 
deviation  from  its  natural  course.  The  inferior  profunda, 
if  large,  or  the  ulnar  nerve,  may  sometimes  be  mistaken 
for  this  vessel. 

Branches  of  the  Brachial  Artery. — The  superior  pro- 
fnnda  is  given  off  generally  opposite  the  lower  border  of 
the  teres  major,  and  accompanies  the  musculo-spiral 
nerve;  the  nutritious  artery  enters  the  nutrient  canal 
near  the  insertion  of  the  coraco-brachialis,  and  passes 
downwards  towards  the  elbow-joint;  the  inferior  pro- 
funda accompanies  the  ulnar  nerve ;  the  anastomotica 
magna  arises  on  the  inner  side,  about  two  inches  above 
the  elbow-joint,  and  lies  between  the  brachialis  anticus 
and  median  nerve,  crossing  the  latter,  and  finally  divides 
into  two  large  branches.  In  applying  a  ligature  to  the 
lower  portion  of  the  main  trunk,  the  position  of  this 
vessel  is  of  importance,  as  it  is  the  chief  means  of  carry- 
ing on  the  collateral  circulation. 

Collateral  Circulation. — After  ligature  above  the  origin 
of  the  profunda  superior,  the  posterior  circumflex  and 
subscapular,  anastomosing  with  the  ascending  branches 
of  the  profunda,  carry  on  the  circulation ;  if  below,  the 
superior  and  inferior  profunda,  inosculating  with  the 
recurrent  branches  of  the  radial,  ulnar,  and  interosseous, 
would  maintain  it. 


THE    BRACHIAL    REGION.  145 

The  action  of  the  muscles  attached  to  the  humerus  upon 
the  fragments  in  fractures  of  this  bone,  are  generally  as 
follows :  If  below  the  insertion  of  the  muscles  attached 
to  the  bicipital  groove,  but  above  the  insertion  of  the 
deltoid,  this  muscle  drags  the  lower  fragment  upwards 
and  outwards,  whilst  the  former  set  draw  it  towards  the 
trunk.  If  below  the  insertion  of  the  deltoid,  the  action 
of  the  muscles  depends  upon  the  direction  of  the  fracture ; 
that  is  to  say,  whether  it  be  oblique  or  transverse. 

Bearing  in  mind  that  the  period  of  union  of  the  shaft 
and  its  epiphysis  is  about  the  thirteenth  year,  we  have 
an  important  diagnostic  point,  in  cases  of  difficulty,  be- 
tween fractures  immediately  above  the  condyles,  sepa- 
ration of  the  epiphysis,  and  dislocation  of  both  radius 
and  ulna  backwards.  If  the  fracture  exists,  the  crepita- 
tion and  ready  reduction  of  the  bones  to  their  normal 
position  would  distinguish  it  from  dislocation.  Again, 
if  instead  of  being  transverse,  the  fracture  of  the  shaft 
be  oblique,  in  a  direction  from  above  downwards  and 
forwards,  the  triceps  will  draw  the  lower  fragment  up- 
wards and  backwards;  if  oblique  in  a  contrary  direction, 
the  lower  fragment  would  be  drawn  upwards  and  for- 
wards by  the  brachialis  anticus  and  biceps. 

Owing  to  the  attachment  of  the  flexors  and  extensors 
of  the  wrist  and  fingers  to  the  condyles,  unless  the  fore- 
arm be  also  put  up  in  an  angled  splint,  there  is  great 
liability  to  ununited  fracture,  as  any  movement  of  the 
wrist  would  tend  to  displace  or  rotate  the  lower  frag- 
ment. 


146  SURGICAL    ANATOMY    OF 


SUKGICAL  ANATOMY  OF  THE  KEGION  OF  THE 
ELBOW. 

Surface  Markings. — This  region  includes  the  articu- 
lation of  the  elbow-joint,  and  its  immediate  relations 
present  for  superficial  examination  four  surfaces.  Sup- 
posing the  forearm  fixed  at  a  right  angle  with  the  hume- 
rus,  a  hollow  is  formed  in  front  by  the  muscles  attached 
to  the  condyles,  within  which  lies  the  tendon  of  the 
biceps,  its  margin  sharp  externally,  and  flattened  in- 
ternally where  its  fascia  is  felt  passing  to  the  muscular 
mass  attached  to  the  inner  condyle,  and  below  which 
can  be  seen  or  felt  the  pulsation  of  the  brachial  artery ; 
beneath  the  skin  are  visible,  particularly  in  thin  per- 
sons, the  superficial  veins  of  the  bend  of  the  elbow.  On 
the  outer  side  can  be  felt  the  external  condyle,  and  the 
head  of  the  radius;  internally,  the  inner  condyle;  whilst 
posteriorly r,  nearer  the  inner  than  the  outer  condyle,  is 
the  olecranon,  with  the  insertion  of  the  triceps  tendon. 

The  mutual  relations  of  these  structures  to  each  other 
should  be  carefully  examined  in  every  position  of  the 
normal  arm,  in  extreme  and  intermediate  flexion  and 
extension,  and  in  pronation  and  supi nation  of  the  fore- 
arm, and  in  cases  of  injury  compared  with  the  opposite 
side.  In  complete  extension,  the  olecranon  is  above  the 
level  of  the  condyles;  in  semiflexion,  on  the  same  level ; 
and  in  flexion,  at  a  right  angle  below  the  level  of  the 
condyles. 

Superficial  Dissection  of  Bend  of  Elbow:  Anterior  As- 
pect — On  reflecting  the  skin,  which  is  thin,  lax,  and 
thrown  into  folds,  beneath  the  subcutaneous  cellular 
tissue  lie  the  cutaneous  nerves,  and  an  important  plexus 
of  veins  and  lymphatics.  The  nerves  are  derived  from 


THE  REGION  OF  THE  ELBOW.        147 

the  internal  cutaneous,  lesser  internal  cutaneous,  median 
and  musculo-cutaneous.  The  superficial  veins  are  de- 
rived principally  from  the  radial,  ulnar,  and  median 
veins,  and  at  the  outer  border  of  the  biceps  tendon  the 
median  joins  the  basilic,  by  means  of  a  large  oblique 
branch,  the  median  basilic;  and  also  the  cephalic,  by  a 
similar  branch  ;  the  median  cephalic,  directed  along  the 
lower  border  of  the  biceps.  At  the  point  of  bifurcation, 
the  aponeurosis  of  the  forearm  is  perforated  by  a  com- 
munication between  these  veins  and  those  accompanying 
the  brachial  artery,  also  between  the  superficial  and  deep 
lymphatics.  The  aponeurosis  of  the  bend  of  the  elbow 
is  a  continuation  of  the  brachial,  and  is  strengthened 
internally  by  an  offset  from  the  tendon  of  the  biceps 
(the  bicipital  fascia).  It  is  this  process  which  separates 
the  median  basilic  vein  from  the  brachial  artery.  It 
receives,  moreover,  posteriorly,  a  slip  from  the  tendon 
of  the  triceps,  is  attached  to  both  condyles,  and  has  a 
further  slip  from  the  brachialis  anticus  tendon. 

On  reflecting  the  aponeurosis,  the  mass  of  muscles 
which  form  the  boundaries  of  the  space  are  brought  into 
view.  Externally,  from  above  downwards,  in  order,  are 
the  supinator  longus,  extensor  carpi  radialis  longior  and 
brevior,  covering  the  lower  and  external  part  of  the 
humerus,  and  the  external  lateral  ligament.  Internally, 
the  common  tendon  of  origin  of  the  flexors  and  prona- 
tors  of  the  wrist  and  forearm  above ;  and  passing  between 
these  muscular  masses  are,  externally,  the  tendon  of  the 
biceps ;  internally,  the  tendon  of  the  brachialis  anticus, 
covering  in  the  anterior  part  of  the  articulation,  part  of 
the  head  of  the  radius,  and  the  coronoid  process.  These 
muscles  form  two  wedge-like  troughs,  in  the  outer  of 
which  lie  the  musculo-spiral  nerve,  superior  profunda 


148  SURGICAL    ANATOMY    OF 

and  radial  recurrent  vessels ;  in  the  inner,  the  brachial 
artery,  its  venaB  comites,  and  the  median  nerve. 

The  braehial  artery  at  the  bend  of  the  elbow  lies  in  the 
middle  of  this  space,  at  first  superficial,  and  afterwards, 
before  it  divides,  deep,  and  opposite  the  coronoid  process 
forms  the  radial  and  ulnar,  and  has  the  following  rela- 
tions :  In  front,  integument  and  superficial  fascia,  me- 
dian basilic  vein,  bicipital  fascia ;  externally,  tendon  of 
biceps ;  internally,  median  nerve  ;  posteriorly,  the  brachi- 
alis  anticus. 

The  lymphatics  are  both  superficial  and  deep,  the 
former  lying  upon  the  aponeurosis,  and  communicating 
with  one  or  more  large  ganglia  immediately  over  the 
anterior  aspect  of-  the  inner  condyle ;  these  ganglia  be- 
come enlarged  in  poisoned  wounds  of  the  finger,  and  in- 
durated in  constitutional  syphilis.  The  deep  ones  fol- 
low the  course  of  the  arteries.  This  aspect  of  the  region 
is  of  the  highest  surgical  importance,  as  in  the  operation 
of  bleeding  from  the  median  basilic  vein,  there  is  a  chance 
of  wounding  the  brachial  artery ;  in  the  event  of  such 
an  accident  occurring,  either  an  aneurismal  varix,  or 
varicose  aneurism,  or  a  diifuse  or  circumscribed  trau- 
matic aneurism,  might  be  the  result.  Arterial  hemor- 
rhage from  wounds  in  this  region,  can  be  generally  con- 
trolled by  extreme  flexion  of  the  arm,  aided  by  a  pad  of 
lint  or  small  roller.  Owing  to  the  great  number  of  inos- 
culating vessels  lying  round  the  joint,  there  is  considera- 
ble chance  of  secondary  hemorrhage. 

The  posterior  aspect  of  the  region  of  the  elbow  presents 
for  examination  the  olecranon  process  of  the  ulna,  be- 
tween which  and  the  integument  is  a  bursa ;  external  to 
the  olecranon  can  be  felt  the  articulation  of  the  head  of 
the  radius  with  the  capitellum ;  and  internally  a  deep 


THE    REGION    OF    THE    ELBOW.  149 

depression,  between  it  and  the  projecting  inner  condyle, 
in  which  lies  the  ulnar  nerve  and  posterior  ulnar  recur- 
rent artery,  passing  between  the  two  heads  of  the  flexor 
carpi  ulnaris.  The  position  of  this  nerve  must  be  borne 
in  mind  in  resection  of  the  elbow-joint,  and  it  must  be 

FIG.  23. 


Structures  in  relation  with  the  anterior  aspect  of  the  elbow-joint.  1.  Cephalic 
vein.  2.  Basilic  vein  and  internal  cutaneous  nerve.  3.  Musculo-spiral  nerve. 
4.  Median  nerve.  5.  Brachial  artery  and  venae  comites.  6.  Anastomotica  magna. 
7.  Radial  recurrent.  8.  Median  vein.  A.  Biceps.  B.  Triceps,  c.  Supinator 
longus  and  extensor  carpi  radialis  longior  (the  division  between  them  is  not 
evident  enough).  D.  Origins  of  flexors  and  pronators.  E.  Capsule  of  joint.  F. 
Extensor  carpi  radialis  longior.  G.  Pronator  teres.  H.  Supinator  longus.  i. 
Tendon  of  biceps  (beneath  which  and  the  capsule  is  the  brachialis  anticus). 

carefully  isolated,  and  hooked  out  of  the  way  in  the 
subsequent  steps  of  the  operation,  to  avoid  injury.  The 
artery  is  only  protected  in  this  operation  by  the  brachialis 
anticus,  so  that  after  the  bones  are  divided,  the  knife 

13 


150  SURGICAL    ANATOMY    OF 

must  be  used  cautiously.  The  great  vascularity  of  the 
region  of  the  elbow-joint  is,  no  doubt,  one  cause  of  the 
success  attending  its  excision,  the  inosculating  branches 
being  the  superior  and  inferior  profundae,  anastomotica 
magna,  anterior  and  posterior  ulnar  recurrent,  interos- 
seous  recurrent,  and  radial  recurrent.  It  is  worthy  of 
notice  that  the  nutrient  vessels  of  the  humerus,  radius, 
and  ulna  run  towards  the  elbow-joint. 

On  making  a  vertical  section  through  the  elbow-joint, 
the  following  structures  would  be  divided  from  above 
downwards :  Skin  and  integument,  containing  the  su- 
perficial veins  and  nerves  already  described,  aponeurosis 
of  arm,  supinator  longus,  pronator  teres,  brachial  artery 
and  veins,  and  median  nerve  and  musculo-spiral  nerve, 
extensor  carpi  radialis  longior,  tendon  of  biceps,  brachi- 
alis  anticus,  supinator  brevis,  flexor  carpi  radialis,  exten- 
sor carpi  radialis  brevior,  external  and  internal  lateral 
ligaments,  flexor  sublimis,  ulnar  nerve,  extensor  carpi 
ulnaris,  flexor  carpi  ulnaris,  anconeus,  olecranon,  and 
olecranon  bursa,  and  then  the  integument.  The  opera- 
tion of  amputation  through  the  articulation  is  not  one 
frequently  performed,  but  the  flaps  would  contain  these 
structures. 

The  articulation  of  the  elbow-joint  admits  of  flexion 
and  extension,  and  the  direction  of  the  articular  surfaces 
not  being  parallel  to  a  line  drawn  through  the  condyle, 
it  follows  that  the  axis  of  the  forearm  is  not  continuous 
with  that  of  the  arm,  the  trochlear  surface  being  much 
lower  down  than  the  capitellum.  The  ligaments  con- 
necting the  bones  of  the  joint  are  very  strong — namely, 
an  anterior,  a  posterior,  and  two  lateral,  whilst  there  is 
a  very  large  synovial  membrane,  the  arrangement  of 
which,  in  diseases  of  the  articulation,  causes  the  swell- 


THE    FORBAD  '       ^"" 


- 

- 

151 

v, 
ing  to  take  place  posteriorly  on  either  side  of  the  ole- 

cranon,  and  anteriorly  at  the  bottom  of  the  fold  at  the 
bend  of  the  elbow. 

Fractures  of  the  humerus,  in  the  region  of  the  joint, 
frequently  implicate  it,  and  are  to  be  distinguished  from 
dislocation  by  there  not  being  the  change  in  the  normal 
relation  of  three  tuberosities — viz.,  the  olecranon,  epi- 
condyle,  and  epitrochlea.  Almost  any  form  of  disloca- 
tion may  exist,  but  the  most  common  is  that  of  both 
bones  of  the  forearm  backwards,  the  strength  of  the 
lateral  ligaments  being  a  great  obstacle  to  lateral  dis- 
placement. 

The  dislocations  to  which  the  articulations  of  the 
elbow-joint  are  liable  are,  in  the  first  place,  of  both  radius 
and  ulna,  backwards,  outwards,  inwards,  forwards;  of 
the  radius  only,  forwards  and  backwards;  and  of  the 
ulna  only,  backwards.  The  difficulties  in  the  diagnosis 
of  these  several  conditions  are  frequently  enhanced  from 
the  complication  with  fracture  or  separation  of  the 
epiphyses,  the  union  of  which  is  as  follows:  the  outer 
condyle  and  both  portions  of  the  articulating  portions  of 
the  humerus  at  the  sixteenth  or  seventeenth  year,  the  inner 
condyle  at  the  eighteenth  year,  whilst  the  superior  articu- 
lar extremities  of  the  radius  and  ulna  unite  with  their 
shafts  at  puberty. 


SURGICAL  ANATOMY  OF  THE  FOREARM. 

Surface  Markings. — The  region  of  the  forearm,  or 
antebrachial,  may  be  described  as  lying  between  the 
lower  margin  of  that  assigned  to  the  elbow  and  the  first 
fold  seen  before  the  wrist-joint.  In  shape  it  is  that  of  a 
flattened  cone,  which  varies  in  form  according  as  the 


152  SURGICAL    ANATOMY    OF 

limb  is  pronated  or  supinated,  the  roundness  of  its  lateral 
boundaries  being  due  to  the  flexors  and  pronator  teres  on 
the  inner,  and  the  supinators  and  extensors  on  the  outer. 
The  bones,  the  radius  and  ulna,  are  capable  of  being 
felt  almost  entirely  throughout  the  region,  particularly 
the  ulna,  the  posterior  border  of  which  is  subcutaneous 
from  the  olecranon  to  the  styloid  process ;  the  radius, 
however,  has  its  shaft  thickly  covered  with  muscles,  and 
is  felt  with  greater  difficulty,  and  the  several  tendons  of 
the  muscles  clothing  them  are  readily  seen  on  putting 
them  in  action.  The  radial  and  ulnar  pulses  are  seen 
in  the  lower  part,  while  the  radial  can  be  felt  in  the 
upper  along  the  inner  border  of  the  mass  of  muscles  at 
the  radial  side. 

Dissection. — On  removing  the  skin,  which  is  thin  and 
smooth,  and  provided  with  hairs,  the  subcutaneous  fascia 
is  met  with,  containing  a  great  deal  of  fat,  in  which  lie 
the  superficial  veins  and  cutaneous  nerves  and  lym- 
phatics. Beneath  this  layer  is  the  antebrachial  apo- 
neurosis,  continuous  with  that  already  described  at  the 
elbow.  It  is  dense,  tough,  and  by  its  prolongation  forms 
fibrous  sheaths  for  the  muscles  and  other  structures  of 
the  region.  This  general  antebrachial  aponeurosis  may 
be  considered  as  forming  into  two  chief  compartments, 
attached  laterally  to  the  radius  and  ulna;  thus  the  an- 
terior is  bounded  by  the  anterior  lamina,  the  anterior 
surfaces  of  the  radius,  ulna,  and  interosseous  membrane, 
and  the  posterior  by  the  posterior  surface  of  these  bones 
and  the  interosseous  membrane,  and  by  the  aponeurosis. 

The  anterior  aspect  of  the  forearm,  according  to  this 
arrangement,  supposing  the  bones  to  be  midway  between 
pronation  and  supination,  contains  from  the  surface  to 
the  interosseous  membrane,  the  integument  of  the  forearm, 


THE    FOREARM. 


153 


aponeurosis,  the  radial  vessels  and  nerves,  lying  in  a 
cellular  interspace  between  the  radial  and  ulnar  mass  of 
muscles,  pronator  teres  as  far  as  the  middle  third,  pal- 
maris  longus,  flexor  carpi  radialis  and  ulnaris,  on  the 


FIG.  24. 


1*16 ',7      ,5    13 

A  section  through  the  middle  of  the  right  forearm.  1.  Anterior  interosseous 
vessels  and  nerve.  2.  Radial  vessels  and  nerve.  3.  Pronator  teres.  4.  Supinator 
longus.  5.  Flexor  carpi  radialis.  6.  Supinator  brevis.  7.  Flexor  sublimis  digi- 
torum.  8.  Extensores  carpi  radialis  longior  and  brevior.  9.  Flexor  carpi  ulnaris. 
10.  Extensor  ossis  metacarpi  pollicis.  11.  Ulnar  vessels  and  nerve.  12.  Exten- 
sor coinniunis  digitorum.  13.  Flexor profundusdigitorum.  14.  Extensorcarpi 
ulnaris.  15.  Median  nerve.  16.  Posterior  interosseous  vessels  and  nerve.  17. 
Extensor  secundi  internodii  pollicis.  (HEATH.) 

inner  aspect,  and  the  supinator  longus,  extensor  carpi 
radialis,  longior  and  brevior,  beneath  which  muscles  is  the 
supinator  brevis,  the  flexor  sublimis  digitorum,  median 
nerve,  and  ulnar  vessels  and  nerve,  flexor  profundus,  and 
flexor  longus  pollicis,  lying  on  the  bones  and  inter- 


154  SURGICAL    ANATOMY    OF 

osseous  membrane.  In  the  lower  third,  the  tendons  of 
the  muscles  passing  to  the  wrist  lie  over  the  pronator 
quad  rat  us,  and  upon  the  membrane  itself  the  anterior 
interosseous  vessels  and  nerves. 

The  posterior  compartment  contains  from  the  surface  to 
the  bones,  the  extensor  communis  digitorum,  slightly 
covered  in  above  by  the  extensor  carpi  radialis  longior, 
and  lower  down  lying  along  the  extensor  carpi  radialis 
brevior,  extensor  minimi  digiti,  extensor  carpi  ulnaris, 
and  anconeus.  The  second  layer  comprises  the  extensor 
ossis  metacarpi,  primi  and  secundi  internodii  pollicis,  the 
extensor  indicis,  and  the  posterior  interosseous  vessels  and 
nerves.  The  extensors  of  the  thumb  will  be  seen  to 
form  a  sort  of  spiral  round  the  lower  part  of  the  radius ; 
they  are  inclosed  in  a  sheath  which  is  very  liable  to  be 
the  seat  of  severe  teno-synovitis,  especially  met  with  in 
reapers  and  workmen. 

Relations  of  the  Radial  Artery  in  the  Forearm. — Sup- 
posing the  vessel  to  be  normal,  a  line  drawn  from  the 
middle  of  the  bend  of  the  elbow  to  the  inner  side  of  the 
styloid  process  of  the  radius  represents  its  course  in  the 
upper  third ;  it  is  concealed  by  the  pronator  teres  and  by 
the  edge  of  the  supinator  longus,  and  lies  on  the  tendon 
of  the  biceps,  and  in  a  bed  of  fat  and  cellular  tissue,  in 
relation  with  some  muscular  branches  of  the  musculo- 
spiral  nerve,  and  on  the  supinator  brevis.  In  the  middle 
third  it  lies  between  the  tendons  of  the  flexor  carpi 
radialis  and  supinator  longus,  having  the  radial  nerve  to 
its  outer  side,  and  on  the  pronator  teres  and  flat  head  of 
the  flexor  sublimis.  In  the  inferior  third  it  has  the  same 
tendons  on  either  side,  whilst  it  rests  upon  the  flexor 
longus  pollicis,  pronator  quadratus,  and  radius.  It  is 
accompanied  throughout  by  vense  comites. 


THE    FOREARM.  155 

To  tie  the  Radial  Artery. — The  vessel  is  readily  secured 
throughout  its  course,  and  any  incisions  made  through 
the  integument  along  the  margin  of  the  stipinator  or  its 
tendon  would  reach  it,  but  its  deligation  on  the  upper 
third  is  only  required  in  cases  of  wound  or  operation, 
which,  in  the  former  instance,  would  be  enlarged,  and 
the  vessel  tied  above  and  below  the  point  of  injury.  The 
vessel  is  liable  to  several  irregularities,  the  most  common 
of  which  is  a  high  origin  from  the  brachial  when  it  lies 
often  merely  subcutaneous  and  can  be  seen  pulsating 
throughout  its  course. 

Relations  of  the  TJlnar  Artery  in  the  Forearm. — Arising 
at  the  bifurcation  of  the  brachial,  it  runs  obliquely  down- 
wards, on  the  ulnar  side  of  the  arm  towards  the  radial 
side  of  the  pisiform  bone,  and  in  its  upper  third  it  is 
covered  by  the  pronator  teres,  flexor  carpi  radialis,  pal- 
maris  longus,  and  flexor  sublimis,  and  having  on  its  inner 
side  the  flexor  carpi  ulnaris,  on  its  outer  the  flexor  sub- 
limis, and  resting  on  the  brachialis  anticus.  In  the 
lower  two-thirds,  it  is  covered  in  by  the  fasciae ;  on  its 
inner  side  are  the  flexor  carpi  ulnaris  and  ulnar  nerve, 
on  its  outer  the  flexor  sublimis,  and  it  rests  on  the  flexor 
profundus;  venae  comites  accompany  it  throughout. 
This  vessel  occasionally  arises  high  up,  when  it  also  lies 
immediately  beneath  the  integument  and  fasciae,  uncover- 
ed by  muscles.  The  same  remarks,  with  regard  to  tying  it 
in  the  upper  third  of  the  arm,  may  be  made  as  have  been 
in  the  case  of  the  radial.  It  is  very  difficult  to  secure  in 
its  upper  third,  owing  to  being  so  covered  in  by  muscles. 

The  nerves  of  the  forearm  are  cutaneous  and  deep,  the 
former  being  branches  of  the  external  and  internal  cutane- 
ous as  far  as  the  wrist,  of  the  lesser  internal  cutaneous 


156  SURGICAL    ANATOMY    OF 

and  musculo-spiral,  and  in  the  lower  third  of  the  ulnar 
and  radial. 

The  musculo-spiral  enters  the  forearm  between  the 
brachialis  anticus  and  supinator  longus,  and  after  break- 
ing up  in  the  supinator  brevis  is  distributed  to  the  ex- 
tensors and  supinators;  the  median  enters  the  forearm 
between  the  two  heads  of  the  pronator  teres  and  is  ac- 
companied by  a  vessel,  the  comes  brevis  mediani,  which 
is  occasionally  of  considerable  size,  and  may  form  one  of 
the  chief  supplies  to  the  palm ;  the  ulnar  enters  the  fore- 
arm between  the  two  heads  of  the  flexor  carpi  ulnaris, 
and  accompanies  the  artery  of  the  same  name. 

In  amputation  through  the  upper  third  of  the  forearm 
the  flaps  would  contain  the  structures  as  follows :  In  the 
anterior,  integument  and  superficial  veins  and  nerves, 
the  flexor  carpi  radialis,  supinator  longus,  pulmaris  lon- 
gus,  flexor  carpi  ulnaris,  extensor  carpi  radialis  longior, 
pronator  teres,  flexor  sublimis  and  profundus,  and  the 
radial,  ulnar,  and  anterior  interosseous  vessels  and  nerves. 
The  posterior ,  the  extensor  carpi  radialis  brevior,  supi- 
nator brevis,  and  the  ulnar  and  common  extensor  of  the 
fingers,  with  the  posterior  interosseous  vessels  and  nerves, 
integuments,  and  superficial  veins  and  nerves.  The 
vessels  requiring  ligature  are  the  radial  and  ulnar,  which 
will  be  found  just  beneath  the  integument,  the  anterior 
and  posterior  interosseous,  which  retract  along  the  inter- 
osseous membrane,  and  perhaps  the  comes  nervi  mediani. 

In  performing  the  flap  amputation  the  bones  should 
be  placed  midway  between  pronation  and  supination ; 
and  in  cases  of  fracture  of  one  or  both  bones,  the  same 
position  must  be  maintained,  as  they  are  then  most  nearly 
parallel  and  furthest  separated  from  each  other,  and  there 
is  less  chance  of  any  union  between  them.  Moreover, 


THE    WRIST    AND    BACK    OF    HAND.  157 

owing  to  the  tendency  to  motion  that  exists  between  these 
bones,  a  false  joint  may  be  the  result  unless  accurate 
adaptation  and  perfect  rest  be  maintained. 

The  fractures  which  occur  in  the  forearm  are  those 
affecting  either  one  or  both  bones  and  their  processes.  If 
the  coronoid  process  be  fractured,  a  rare  accident,  depen- 
dent on  muscular  action  or  dislocation,  that  amount  of 
flexion  performed  by  the  brachialis  anticus  is  necessarily 
lost ;  symptoms  of  fracture  of  the  olecranon  are  obvious, 
and  the  powerful  action  of  the  triceps  in  separating  the 
fragments  accounts  for  the  rarity  of  bony  union ;  more- 
over, the  articulation  is  generally  opened.  If  the  neck 
of  the  radius  be  fractured,  a  result  of  direct  violence,  the 
diagnosis  is  obscure,  and  must  be  deduced  from  the  want 
of  power  of  voluntary  pronation  and  supination. 

The  action  of  the  muscles  of  the  forearm  upon  fragments 
is  well  marked  in  such  a  case  as  fracture  of  the  shaft  of 
the  radius  alone.  Thus,  supposing  it  broken  about  its 
centre,  the  upper  fragment  is  drawn  forwards  by  the 
biceps,  inwards  by  the  pronator  teres ;  the  lower  frag- 
ment is  pronated  and  drawn  downwards  and  inwards  by 
the  pronator  quadratus,  and  its  styloid  process  tilted 
upwards  by  the  supinator  longus.  In  fractures  of  both 
bones  the  action  of  the  muscles  often  causes  great  de- 
formity. 

SURGICAL  ANATOMY  OF  THE  REGION  OF  THE 
WRIST  ANJ)  BACK  OF  HAND. 

Surface  Markings. — Beneath  the  integuments  are  seen 
the  cutaneous  veins  and  the  tendons  of  the  muscles  act- 
ing on  the  wrist  and  fingers,  the  anterior  ones  being 
most  evident  in  flexion  of  the  hand  or  clenching  the  fist, 

14 


158          SURGICAL    ANATOMY    OF    THE    REGION 

especially  the  palmaris  longus  and  flexor  carpi  radialis ; 
the  posterior,  in  extension  of  the  wrist  or  fingers,  and  in 
extension  of  the  thumb.  The  position  of  the  styloid  pro- 
cesses of  the  radius  and  ulna  can  be  felt,  the  former 
lower  down  than  the  latter;  the  relation  of  these  pro- 
cesses, however,  is  altered  during  pronation  and  supina- 
tion.  In  front  of  the  styloid  process  of  the  radius  is  the 
root  of  the  thumb  and  prominence  of  the  scaphoid,  and 
on  the  inner  side  is  the  pisiform  bone,  with  the. flexor 
carpi  ulnaris  attached  to  it.  The  pulsations  of  the 
radial  and  ulnar  arteries  can  be  easily  felt  and  gener- 
ally seen ;  the  former  on  the  radial  side  of  the  flexor 
carpi  radialis ;  the  latter  on  the  radial  side  of  the  flexor 
carpi  ulnaris. 

Dissection. — On  reflecting  the  skin,  the  subcutaneous 
cellular  tissue  is  seen,  free  from  fat,  and  lying  in  it  are 
the  cutaneous  vessels,  nerves,  and  lymphatics.  The 
aponeurosis  is  a  continuation  of  that  forming  the  sheath 
of  the  muscles  of  the  forearm,  which  is  remarkable  at 
the  wrist  as  being  very  strong,  and  affording  special 
channels  for  the  passage  of  the  tendons  of  the  muscles 
of  the  forearm.  It  consists  of  two  portions — an  ante- 
rior, very  thick  and  strong  (anterior  annular  ligament), 
continuous  with  the  deep  fascia  of  the  forearm,  which  is 
attached  to  the  pisiform,  unciform,  radius,  scaphoid  and 
trapezium  bones,  receiving  an  expansion  of  the  tendon  of 
the  palmaris  longus,  and  forming  an  arch  between  the 
thenar  and  hypothenar  regions ;  and  a  posterior,  dense, 
and  formed  of  circular  and  longitudinal  bundles  of  tissue 
attached  to  the  ulna,  cuneiform,  pisiform  bones,  to  the 
radius,  and  to  the  several  eminences  on  its  dorsal  aspect, 
which  separate  the  extensor  tendons,  and  is  thus  divided 


OF    THE    WRIST    AND    BACK    OF    HAND.          159 

into  six  compartments,  each  lined  with  a  separate  sy no- 
vial  membrane. 

Anterior  Region  of  Wrist. — The  first  layer  of  struc- 
tures beneath  the  integument  and  aponeurosis  of  the 
wrist,  and  described  from  the  radial  towards  the  ulnar 
side,  consists  of — the  supinator  longus,  the  radial  ves- 
sels, the  flexor  carpi  radialis  and  palmaris  longus,  the 
former  of  which  perforates  the  denser  portion  of  the  an- 
nular ligament,  the  ulnar  vessels  and  nerve,  and  the 
flexor  carpi  ulnaris.  All  these  tendons  have  separate 
sheaths,  derived  from  the  annular  ligament  and  synovial 
membranes.  The  second  layer  consists  of  the  flexor 
sublimis,  enveloped  in  synovial  membrane,  and  .the 
median  nerve,  with  its  accompanying  artery.  The  third 
consists  of  the  flexor  longus  pollicis  and  the  flexor  pro- 
fundus  digitorum,  having  their  synovial  sheaths  in 
common  with  the  superficial  flexor,  while  close  on  the 
bone  are  the  carpal  branches  of  the  radial  and  ulnar. 

The  Posterior  Region. — Between  the  skin  of  the  back 
of  the  hand  and  the  subcutaneous  tissue  are  a  number  of 
superficial  veins  and  cutaneous  nerves,  derived  from  the 
radial  and  dorsal  branch  of  the  ulnar.  Beneath  them  is 
a  strong  fibrous  membrane,  apparently  continuous  with 
the  dorsal  portion  of  the  annular  ligament.  There  is  a 
deeper  layer,  covering  the  bones  and  interossei,  which  is 
blended  with  the  palmar  aponeurosis  laterally,  and  the 
dorsal  tendons  pass  between  these  layers.  Beneath  the 
annular  ligament  are  the  six  compartments  for  the  fol- 
lowing tendons,  beginning  on  the  radial  side :  (1)  exten- 
sores  ossis  metacarpi  and  primi  internodii  pollicis ;  (2) 
extensores  carpi  radialis,  longior,  and  brevior ;  (3)  ex- 
tensor secundi  internodii  pollicis,  crossing  the  two  former 
very  obliquely;  (4)  extensores  digitorum,  and  indicis  ; 


160          SURGICAL    ANATOMY    OF    THE    REGION 

(5)  extensor  minimi  digiti ;  (6)  extensor  carpi  ulnaris. 
The  sy  no  vial  membrane  investing  their  anterior  surfaces 
being  very  thin  and  indistinct,  is  more  frequently  the 
seat  of  ganglion  than  that  of  the  flexor  tendons. 

The  tendons  of  the  extensor  muscles,  having  arrived 
at  the  metacarpo-phalangeal  articulation,  receive  the 
tendons  of  the  lumbricales  and  interossei,  whilst  at  the 
first  phalangeal  joint  they  divide  into  three  fasciculi,  the 
central  one  being  inserted  into  the  base  of  the  second 
phalanx,  and  the  two  lateral  passing  on  and  reuniting, 
are  inserted  into  the  base  of  the  ungtial.  They  have  no 
distinct  synovial  sheaths. 

The  radial  artery  at  the  wrist  can  be  felt  or  seen  beat- 
ing between  the  tendons  of  the  flexor  carpi  radialis  and 
supinator  longus,  where  it  is  quite  superficial  and  easily 
secured.  Accompanied  by  vense  comites,  it  winds  round 
the  outside  of  the  wrist,  to  gain  the  first  interosseous 
space,  when  it  enters  the  palm  between  the  two  heads  of 
the  first  dorsal  interosseous,  and  is  crossed  by  the  exten- 
sors of  the  thumb.  It  is  readily  secured  at  the  base  of 
the  well-marked  hollow  formed  by  these  muscles.  In 
disarticulation  of  the  metacarpal  bone  of  the  thumb  it 
stands  a  chance  of  being  divided,  but  if  the  knife  be  kept 
close  to  the  bone  it  can  be  avoided.  The  most  important 
branch  of  the  radial  is  the  superficial  volar,  which  ordi- 
narily lies  subcutaneously,  and  completes  the  superficial 
arch.  The  other  branches  given  off  at  the  wrist  supply 
the  carpus  and  dorsal  aspects  of  the  thumb  ancl  first 
finger. 

The  ulnar  artery,  at  the  wrist,  lies  with  its  venaa 
comites  on  the  radial  side  of  the  flexor  carpi  ulnaris,  and 
with  its  nerve  to  its  inner  side. 

Articulations  of  the  Wrist-joint. — These  are  the  inferior 


OF    THE    WRIST    AND    BACK    OF    HAND.          161 

radio-ulnar,  the  radio-carpal,  which  exist  between  the 
lower  end  of  the  radius,  the  scaphoid,  and  semilunar 
bones.  The  synovial  membrane  of  this  articulation  is 
also  extended  over  the  cuneiform  bone  and  the  inter- 
articular  fibre-cartilage  between  the  ulna  and  that  bone; 
the  intercarpal  and  carpo-rnetacarpal  joints,  which  in- 
clude the  anterior  articular  surfaces  of  the  cuneiform, 
semilunar,  and  scaphoid,  the  entire  unciform,  os  magnum, 
and  trapezoid,  with  the  bases  of  the  four  inner  metacar- 
pals,  have  a  common  synovial  membrane,  whilst  the 
pisiform  and  the  trapezium  have  one  each.  Of  these 
articulations  the  most  important  to  the  surgeon  is  the 
radio-carpal,  as  dislocation  of  the  hand  and  carpus  from 
the  radius,  either  backwards  or  forwards,  takes  place 
here.  Moreover,  amputation  is  occasionally  performed 
at  this  joint. 

Fracture  of  the  radius  just  above  the  articulation 
(Colles's  fracture),  is  almost  always  transverse,  and  in 
young  subjects  is  a  separation  of  the  lower  epiphyses. 
The  deformity  is  well  marked ;  the  result  of  the  com- 
bined action  of  the  supinator  longus,  extensors  of  thumb, 
and  radial  extensors  of  the  wrist,  causes  the  lower  frag- 
ment to  make  a  partial  rotation  on  its  transverse  axis. 

In  examining  the  lower  end  of  the  forearm,  in  cases 
of  injury,  it  must  be  remembered  that  the  head  of  the 
ulna  is  prominent  in  pronation,  and  its  styloid  process  in 
supination,  owing  to  the  rotation  of  the  radius  at  its  in- 
ferior radio-ulnar  articulation. 

Amputation  at  the  wrist-joint  may  be  performed  either 
by  a  semilunar  dorsal  flap,  and  an  anterior,  formed  from 
the  palm,  or  by  rectangular  flaps.  The  knife  may  get 
notched  against  the  pisiform  bone,  so  that  some  little 
neatness  is  necessary  in  avoiding  it.  The  styloid  pro- 


162  SURGICAL    ANATOMY    OF    THE    PALM. 

cesses  of  the  radius  and  ulna  require  removal,  and  the 
vessels  which  would  be  ligatured  are  the  superficialis 
volse,  some  branches  of  the  ulnar  in  the  palm,  and  per- 
haps an  abnormal  median. 

For  the  operation  of  excision  of  the  joint,  an  accurate 
knowledge  of  its  component  parts  and  relations  is  of  the 
utmost  importance,  as  this  excision,  like  that  of  the 
ankle,  reduces  itself  to  an  anatomical  problem — viz.,  to 
remove  the  disease,  and  at  the  same  time  to  preserve  to 
the  hand  the  tendons  passing  from  the  arm  to  it,  and  if 
possible  to  retain  their  functions.  It  is  difficult  to  lay 
down  any  distinct  rules,  as  obviously  each  case  has  its 
own  peculiarities ;  but  by  far  the  most  scientific  pro- 
ceeding is  that  of  Professor  Lister,  for  an  account  of 
which  somewhat  complicated  but  most  successful  opera- 
tion, reference  must  be  made  to  special  works  on  opera- 
tive surgery. 

SURGICAL  ANATOMY  OF  THE  PALM. 

Surface  Markings. — This  region  extends  from  the  wrist 
to  the  web  of  the  fingers.  It  is  concave,  and  presents 
two  muscular  eminences:  one  on  the  radial  side,  due  to 
the  mass  of  muscles  acting  on  the  thumb,  called  the 
.thenar  prominence,  and  the  other  due  to  muscles  of  the 
little  finger,  the  hypothenar.  The  intermediate  space  is 
marked  by  several  furrows,  indicating  the  more  marked 
flexions  of  the  hand,  one  of  which,  the  oblique  central 
one,  lies  almost  in  the  course  of  the  superficial  palmar 
arch.  The  deep  palmar  arch  may  be  referred  to  the 
surface  marking,  by  an  imaginary  line  drawn  between 
the  centres  of  those  circles,  which  form  the  bases  of  the 
thenar  and  hypothenar  eminences.  The  bifurcation  of 


SURGICAL    ANATOMY    OF    THE    PALM.  163 

the  digital  vessels  takes  place  a  little  nearer  the  palm 
than  the  web  of  the  fingers,  and  their  course  is  subse- 
quently along  the  under  lateral  aspects  of  the  digits. 
The  skin  is  very  sensitive,  notwithstanding  the  horny 
condition  it  acquires  in  those  who  have  much  manual 
labor,  and  it  is  furrowed  by  ridges,  in  which  lie  the 
orifices  of  the  sweat-ducts.  The  great  vascularity  of  the 
skin  of  the  palm  predisposes  this  region  to  the  occur- 
rence of  erectile  tumors. 

Dissection. — The  subcutaneous  tissue  is  full  of  lobu- 
lated  fat ;  beneath  the  fat  and  cellular  tissue  is  the  palmar 
fascia,  particularly  strong  in  its  central  fasciculus,  and 
into  the  posterior  portion  of  which  is  inserted  the  pal- 
maris  longus;  opposite  the  heads  of  the  metacarpal  bones 
it  divides  into  four  slips,  which  slips  themselves  will  be 
seen  to  divide  into  two  processes,  attached  to  the  sides 
of  the  first  phalanx,  giving  passage  to  the  flexor  ten- 
dons, whilst  the  intermediate  spaces  transmit  the  digital 
vessels  and  nerves.  Vertical  septa  pass  down  and  divide 
the  central  set  of  palmar  muscles  from  the  thenar  and 
hypothenar,  the  expansion  of  the  palmar  fascia  covering 
which  is  very  thin.  This  palmar  aponeurosis  is  fre- 
quently the  seat  of  contraction  which  implicates  the 
fingers.  The  little  palmaris  brevis  muscle  is  attached  to 
the  skin  and  ulnar  aspect  of  the  central  portion  of  the 
aponeurosis.  On  removing  the  palmar  fascia  the  under- 
lying structures  are  met  with  in  the  following  order, 
dissecting  down  to  the  metacarpus. 

Commencing  with  the  thenar  eminence  beneath  the 
fascial  covering,  lie  the  superficialis  volse  artery,  abduc- 
tor pollicis,  opponens  pollicis,  and  radial  head  of  short 
flexor  of  thumb,  tendon  of  flexor  longus  pollicis,  ulnar 
head  of  flexor  brevis  pollicis,  princeps  pollicis,  and 


164  SURGICAL    ANATOMY    OF    THE    PALM. 

radialis  indicis  arteries,  metacarpal  bone  of  thumb,  tra- 
pezium, and  tendon  of  flexor  carpi  radialis. 

In  the  middle  segment  of  the  palm,  beneath  the  central 
fasciculus  of  the  palmar  fascia  and  the  anterior  annular 
ligament,  with  which  the  fascia  is  continuous,  lies  the 
superficial  palmar  arch  and  its  digital  branches,  the  ul- 
nar  and  median  nerves  with  their  digital  branches,  the 
tendons  of  the  flexor  sublimis  and  profundus  digitorum, 
with  which  latter  are  associated  the  lumbricales  (these 
muscles  inclosed  in  their  sy  no  vial  sheaths),  next  a  layer 
of  fibrous  tissue  separating  them  from  the  deep  arch,  the 
deep  branch  of  the  ulnar  artery,  the  adductor  of  thumb 
and  interossei,  whose  tendons  with  those  of  the  lumbri- 
cales pass  into  the  general  dorsal  aponeurosis,  and  lastly, 
the  metacarpus. 

Beneath  the  palmar  fascia  of  the  hypothenar  eminence 
lie  the  palmaris  brevis,  some  cutaneous  vessels  and  nerves, 
the  abductor  and  flexor  brevis,  minimi  digiti,  commence- 
ment of  superficial  palmar  arch,  with  its  accompanying 
ulnar  nerve,  opponens  minimi  digiti,  deep  branch  of  ul- 
nar artery  and  nerve,  and  fifth  metacarpal  bone. 

The  metacarpal  bone  of  the  thumb  articulates  with 
the  trapezium  by  a  saddle-shaped  surface,  and  its  shaft 
is  considerably  curved  anteriorly;  and  in  amputation  at 
the  metacarpo-trapezial  joint,  the  secret  of  enucleating 
the  bone  neatly  consists  in  abducting  it  forcibly  and  di- 
viding the  lateral  ligaments,  of  which  it  is  better  to  cut 
the  inner  one  first.  There  are  several  methods  of  per- 
forming this  operation,  but  that  should  always  be  chosen 
which  will  leave  the  greatest  amount  of  opposing  tissue; 
as  the  muscular  pad,  resulting  from  the  flaps,  even 
though  it  lose  its  bony  support,  is  of  great  importance 
when  the  hypothenar  mass  of  muscle  is  intact,  as  it  will 


SURGICAL    ANATOMY    OP    THE    PALM.  165 

in  great  measure  retain  the  power  of  approximation. 
Care  must  be  taken  to  avoid  wounding  the  trunk  of  the 
radial  artery  as  it  passes  between  the  two  heads  of  the 
first  dorsal  interosseous  muscle,  if  possible.  The  meta- 
carpal  bones  of  the  fingers,  having  a  common  synovial 
membrane  with  their  carpal  bones,  ought,  if  possible,  to 
be  removed  without  disarticulation,  owing  to  the  lia- 
bility of  general  suppuration.  There  is  some  little  diffi- 
culty attending  amputation  of  the  fifth  metacarpal  bone, 
owing  to  its  double  articulation  with  the  os  cuneiforme. 

Abscess  in  the  palm  (palmar  abscess),  unless  opened 
early,  is  liable  to  spread  up  the  arm,  along  the  synovial 
sheaths  of  the  muscles,  by  passing  beneath  the  annular 
ligament,  the  excruciating  pain  attending  it  being  due 
to  the  tenseness  of  the  palmar  fascia.  In  opening  col- 
lections of  pus  in  the  palm,  the  position  of  the  palmar 
arch  must  be  recollected,  and  the  knife  should  be  entered 
upon  the  head  or  neck  of  the  metacarpal  bone,  and  not 
between  the  fingers,  so  that  the  bifurcation  of  the  digital 
artery  may  be  avoided. 

In  wounds  of  the  palmar  arch,  if  ligature  of  the  radial 
and  ulnar  fail,  the  circulation  is  probably  carried  on  by 
an  enlarged  anterior  interosseous  or  comes  nervi  medi- 
ani,  and  ligature  of  the  brachial  must  be  had  recourse  to. 

Bursal  tumors  are  commonly  met  with  in  association 
with  the  synovial  sheaths  of  the  flexor  tendons  in  the 
palm,  and  generally  communicate  beneath  the  annular 
ligament,  with  the  continuation  of  these  sheaths  in  the 
forearm. 

In  the  fingers  the  skin  is  very  thick,  particularly  on 
the  palmar  aspect,  highly  vascular,  and  freely  supplied 
with  nerve-fibres.  The  subcutaneous  tissue  contains  a 
good  deal  of  fat ;  beneath  this  tissue  is  the  sheath  or 


166         SURGICAL    ANATOMY    OF    THE    PALM. 

theca  of  the  flexor  tendons,  an  osseo-fibrous  canal, 
formed  by  the  phalanges  and  a  dense  tube  of  fibrous 
tissue,  disposed  in  circular  and  oblique  bands,  very  thin 
immediately  opposite  the  flexures,  and  perforated  at  the 
roots  of  the  fingers  for  the  passage  of  vessels  and  cellular 
tissue.  The  sheath  is  very  thin  on  the  palmar  aspect  of 
the  ungual  phalanx,  and  purulent  infiltration  into  it  is 
common  at  this  point.  The  flexor  tendons  which  lie  in 
the  sheath,  are  those  of  the  flexor  sublimis  (perforates) 
attached  by  two  slips  to  the  sides  of  the  second  pha- 
langes, and  those  of  the  flexor  profundus  (perforans) 
which  divides  them,  and  is  inserted  into  the  base  of  the 
ungual.  The  canal  is  lined  with  a  synovial  membrane, 
which  is  reflected  on  to  the  tendons.  Slender  tendinous 
filaments,  called  vincula,  connect  these  tendons  to  the 
walls  of  the  canal.  On  the  dorsum  there  is  a  strong 
aponeurosis  formed  by  the  extensor  tendons,  further 
strengthened  by  the  expansion  of  the  interossei  and 
lumbricales.  The  common  extensor  passes  on  to  the 
second  phalangeal  articulation,  opposite  which  it  divides 
into  three  fasciculi,  the  central  one  being  inserted  into 
the  base  of  the  second  phalanx,  whilst  the  two  lateral 
slips  reunite  and  pass  on,  to  be  inserted  into  the  base  of 
the  ungual. 

In  excision  of  the  phalangeal  articulations  it  is  neces- 
sary to  retain  as  much  as  possible  of  this  dorsal  aponeu- 
rosis, in  order  that  the  power  of  extension  may  be  after- 
wards kept.  In  disarticulation  of  a  phalanx,  it  must  be 
remembered  that  immediately  the  lateral  ligament  is 
divided  the  joint  is  opened,  and  that  this  lateral  liga- 
ment does  not  coincide  with  the  palmar  fold  of  the  digit, 
but  is  a  little  in  front  of  it,  so  that  the  guide  for  enter- 


SURGICAL    ANATOMY    OF    THE    PALM.  167 

ing  the  knife  is  the  second  fold  in  the  skin  seen  on  the 
dorsal  aspect  of  the  joint. 

The  vessels  and  nerves  supplying  the  fingers,  includ- 
ing the  thumb,  are  derived  from  the  digital  branches  of 
the  radial  and  ulnar  arteries,  and  ulnar  and  median 
nerves,  the  former  supplying  the  thumb  and  radial  side 
of  the  index,  the  ulnar  side  of  the  index,  and  remaining 
fingers;  and  the  latter  the  little  finger,  half  the  ring 
finger,  and  the  remaining  fingers.  The  arteries  anasto- 
mose very  freely  in  the  pulp  and  matrix  of  nail.  The 
veins  accompany  the  arteries  and  pass  posteriorly,  and 
form  a  considerable  plexus,  passing  along  the  back  of 
the  fingers  into  the  veins  of  the  back  of  the  hand. 

Dislocation  of  the  first  phalanx  of  the  thumb  is  diffi- 
cult of  reduction,  and  if  reduced,  of  being  maintained 
in  position,  owing  to  the  great  power  exerted  by  the 
mass  of  muscles  forming  the  ball  of  the  thumb,  and  to 
the  fact  that  when  the  phalanx  lies  on  the  dorsal  aspect 
of  the  metacarpal  bone,  the  narrow  head  of  the  latter  be- 
comes constricted  by  the  two  terminal  attachments  of 
the  flexor  brevis  pollicis,  the  tendons  of  which  are  fur- 
ther strengthened  by  the  conjoined  insertion  of  the  ad- 
ductor and  abductor. 


168  SURGICAL    ANATOMY    OF 


CHAPTER  V. 

SURGICAL  ANATOMY  OF   THE  ABDOMEN. 

BEFORE  commencing  the  strictly  surgical  anatomy  of 
the  abdomen,  it  will  be  convenient  to  point  out  gener- 
ally, the  relations  of  the  contents  of  this  cavity  to  the 
surface  of  the  body,  considerations  of  importance  to  the 
surgeon  as  aids  to  diagnosis. 

Relations  of  the  Viscera  to  the  Abdominal  Parietes. — 
In  order  to  facilitate  the  description  of  the  abdomen,  it 
can  be  mapped  out  by  certain  arbitrary  lines  into  nine 
regions,  to  which  the  contained  viscera  can  be  referred 
— a  method  of  reference  of  considerable  use  in  a  certain 
way,  but  of  no  great  value  as  bearing  upon  the  subject 
of  Surgical  Anatomy,  properly  so  called.  These  lines 
are  vertical  and  horizontal ;  the  vertical,  passing  from 
the  seventh  costal  cartilage  to  the  middle  of  Poupart's 
ligament,  on  either  side,  and  the  horizontal  through  the 
level  of  the  ninth  costal  cartilages,  and  crests  of  the  ilia. 
The  regions  thus  indicated  are  called  the — 

Right  hypochondriac.         Epigastric.  Left  hypochondriac. 

Right  lumbar.  Umbilical.  Left  lumbar. 

Right  iliac.  Hypogastric.  Left  iliac. 

The  stomach  lies  in  the  epigastric  and  left  hypochon- 
driac regions;  the  transverse  colon  crosses  the  umbilical; 
the  jejunum  and  ileum  occupy  the  umbilical  and  hypo- 
gastric  ;  the  ascending  and  descending  colon  the  iliac  and 


THE    ABDOMEN.  169 

lumbar  of  either  side ;  and  the  kidneys  lie  in  the  right 
and  left  lumbar,  the  spleen,  the  left  hypochondriac. 
The  student  is  frequently  called  upon  to  map  out  or 
percuss  some  larger  viscus — such  for  example,  as  the 
liver — the  position  of  which  is  indicated  as  follows :  It 
fills  the  right  hypochondriac  region  and  concavity  of  the 
diaphragm,  and  is  almost  completely  concealed  by  the 
overhanging  of  the  ribs ;  part  of  the  left  lobe  lies  in  the 
epigastric  and  left  hypochondriac  regions.  It  projects 
upwards  into  the  thorax,  and  is  separated  from  its  wall 
by  the  thin  lower  margin  of  the  right  lung  and  the  dia- 
phragm. In  this  region  its  upper  margin  is  about  the 
fifth  intercostal  space ;  referred  to  a  line  drawn  from  the 
posterior  boundary  of  the  axilla  vertically  to  the  crest 
of  the  ilium,  its  margin  would  be  about  the  seventh  in- 
tercostal space.  In  the  mesial  line  it  is  not  easy  to  dis- 
tinguish the  upper  boundary  of  the  liver  from  the  lower 
margin  of  the  heart. 

For  surgical  and  operative  reference,  however,  the  re- 
gions of  the  abdomen  will  be  considered  under  the  heads 
of — (1)  Abdominal  parietes  ;  (2)  Such  portions  of  the 
abdominal  cavity  as  are  of  practical  surgical  importance ; 

(3)  Pelvis. 

(1)  Abdominal  Parietes. 

The  region  of  the  abdominal  parietes  may  be  divided 
as  follows — (1)  Antero-lateral  •  (2)  Inguinal ;  (3)  Crural ; 

(4)  Lumbar. 

(1)  Antero-lateral  Region  of  the  Abdomen — Dissection. — 
On  removing  the  skin,  which  is  very  lax,  excepting  at 
the  umbilical  depression,  is  the  subcutaneous  cellular 
tissue  and  fascia,  which  latter  may  be  divided  into  as 


170  SURGICAL    ANATOMY    OF 

many  lamellae  as  the  skill  of  the  dissector  permits  of;  two 
of  which,  however,  may  be  considered  as  ample  for  all 
surgical  purposes,  the  superficial  and  the  deep.  These 
fasciae  are  continuous,  and  interlace  on  either  side  of  the 
linea  alba,  which  is  seen  as  a  well-marked  depression, 
and  some  of  their  fibres  are  attached  to  it,  and  in  the 
lower  portion  of  the  abdomen  pass  downwards  to  the 
scrotum,  strengthening  the  suspensory  ligament  of  the 
penis,  and  giving  origin  to  the  dartos  (vide  Inguinal 
Region).  In  the  fat  existing  between  these  laminae  lie 
numerous  cutaneous  branches  of  the  superficial  epigas- 
tric and  intercostal  vessels  and  nerves.  Beneath  the 
deeper  layer  is  the  external  oblique  muscle,  the  fibres  of 
origin  of  which  interdigitate  with  those  of  the  serratus 
magnus  and  latissimus  dorsi,  and  its  aponeurosis  passes 
inwards,  to  be  inserted  into  the  iliac  spine,  the  linea 
alba,  and  iliac  and  pubic  crests.  The  fibres  of  this 
muscle  are  oblique  from  above  down  wards.  Beneath  it 
lies  the  internal  oblique,  separated  from  it  by  a  thin 
cellular  interval,  derived  originally  from  the  lumbar 
aponeurosis,  and  in  which  lie  filaments  of  the  lower  in- 
tercostal and  last  dorsal  nerves ;  its  tendon  is  inserted 
into  the  cartilages  of  the  lower  ribs,  the  linea  alba,  and 
ilio-pectineal  line,  inclosing  the  rectus  for  its  upper  two- 
thirds,  and  passing  in  front  of  it  entirely  for  the  remain- 
ing third.  The  fibres  run  in  the  contrary  direction  to 
those  of  the  former  muscle.  The  transversalis  is  sepa- 
rated from  it  by  a  thin  cellular  interval,  and  having  its 
origin  from  the  lower  ribs  and  lumbar  aponeurosis  is  in- 
serted along  the  linea  alba  and  by  the  conjoined  tendon, 
the  upper  three-fourths  passing  behind  the  rectus,  and 
blending  with  the  tendon  of  the  internal  oblique,  whilst 
its  lower  fourth  passes  in  front  of  it.  It  is  separated 


THE    ABDOMEN.  171 

from  the  peritoneum  by  the  transversalis  fascia.  The 
rectus  abdominis  passes  vertically  down  the  abdominal 
parietes,  on  either  side  of  the  linea  alba,  inclosed  in  a 
partial  sheath,  and  having  three  or  four  tendinous  inter- 
sections, which  are  very  readily  seen  beneath  the  skin 
when  the  muscle  is  in  action.  Below  it  is  a  little  mus- 
cle, the  pyramidalis,  attached  below  to  the  pubis  and 
inserted  into  the  linea  alba,  at  the  junction  of  the  middle 
with  the  lower  third  of  the  rectus.  The  continuity  of 
the  thin  aponeurotic  laminae,  which  exist  between  the 
abdominal  muscles,  with  the  lumbar  aponeuroses,  ac- 
counts for  the  occasional  pointing  of  lumbar  abscess  in 
the  parietes  above  Poupart's  ligament,  or  at  the  edge  of 
the  rectus.  The  deep  epigastric  artery,  with  its  veins, 
after  passing  between  the  peritoneum  and  transversalis 
fascia,  gets  behind  it,  and  entering  its  fibres,  freely 
anastomoses  with  the  superior  epigastric  from  the  inter- 
nal mammary,  which  vessel  itself  enters  the  rectus  below 
the  cartilages  of  the  eighth  or  ninth  ribs.  Between  the 
transversalis  fascia  and  the  peritoneum  is  the  subperi- 
toneal  cellular  tissue.  The  peritoneum  itself  closely 
lines  this  region  of  the  abdominal  wall,  excepting  for  a 
short  distance  above  the  pubes,  where  its  attachment  is 
very  lax — a  circumstance  taken  advantage  of  in  punc- 
ture of  the  bladder  in  this  region. 

Operations  for  the  removal  of  abdominal  tumors  and 
for  paracentesis  abdominis  are  performed  in  the  mesial 
line,  as  the  simple  structure  of  the  linea  alba,  present- 
ing no  layers,  does  not  admit  of  infiltration  into  muscu- 
lar aponeuroses  or  sheaths.  In  the  operation  of  para- 
centesis the  parietal  layer  of  the  peritoneum  only  would 
be  involved ;  but  in  operations  on  an  ovarian  cyst,  for 
example,  both  parietal  and  visceral  are  divided.  In 


172  SURGICAL    ANATOMY    OF 

the  case,  however,  of  the  incision  through  the  parietes 
made  for  the  application  of  ligatures  to  the  iliac  arte- 
ries, the  abdominal  muscles  are  divided,  whilst  the  peri- 
toneum is  kept  entire.  The  resilience  of  the  walls  of 
this  region  allows  of  the  ready  manipulation  of  its  con- 
tents, with  a  view  to  diagnosis.  Penetrating  wounds 
are  frequently  followed  by  hernial  protrusion,  on  ac- 
count of  the  laxity  of  their  cicatrices. 

In  the  linea  alba,  between  the  two  recti,  is  the  um- 
bilicus, the  cicatrix  of  a  foetal  structure,  the  umbilical 
cord,  which  having  been  cut  or  tied  at  birth,  has 
shrunk  up  to  its  attachment  at  the  abdominal  parietes, 
and  the  closure  of  the  opening  is  formed  by  tough 
fibrous  tissue,  closely  adherent  to  the  peritoneum  and 
neighboring  tissues. 

Umbilical  hernice,  if  formed  at  an  early  period,  pos- 
sess a  very  thin  covering  of  peritoneum,  as  that  mem- 
brane is  but  recently  formed  at  that  spot,  and  in  almost 
all  cases  this  sac  contains  omentum,  transverse  colon,  or 
small  intestine. 

Umbilical  hernia  is  almost  always  a  congenital  affec- 
tion ;  ventral  hernia,  though  occurring  at  this  spot,  is 
really  a  protrusion  through  a  preternatural  opening  in 
the  fibrous  coverings  close  to  the  umbilicus. 

The  regions  of  the  abdominal  parietes  of  greatest 
interest  to  the  surgeon,  and  which  demand  a  more  accu- 
rate anatomical  description,  are  those  connected  with 
inguinal  and  crural  hernia;  and  though  these  protru- 
sions are  formed  of  structures  contained  in  the  abdomi- 
nal cavity,  they  would  be  best  considered  in  the  rela- 
tions in  which  they  would  present  themselves — namely, 
from  the  surface. 


THE    INGUINAL    REGION.  .  173 

SUEGICAL  ANATOMY  OF  THE  INGUINAL  KEGION. 

Surface  Markings. — This  region  may  be  indicated  by 
a  line  drawn  from  the  anterior  superior  spine  of  the 
ilium  to  the  mesial  line  of  the  body  superiorly,  the 
mesial  line  itself,  internally,  and  Poupart's  ligament, 
below.  Between  the  bony  prominences,  the  anterior 
superior  spine  externally,  and  the  crest  of  the  pubes  in- 
ternally, is  a  curved  furrow,  with  its  convexity  down- 
wards, indicating  the  fold  of  the  groin,  and  the  position 
of  Poupart's  ligament.  Just  above  the  pubes  can  be 
felt  the  external  abdominal  ring,  and  the  structures 
forming  the  cord  are  readily  recognizable. 

Before  commencing  the  dissection,  the  finger  should 
be  passed  up  into  the  external  ring  without  using  any 
force,  by  tucking  up  the  scrotal  tissue  upwards  along 
the  cord,  in  order  to  ascertain  under  what  conditions  of 
the  position  of  the  leg  the  examination  of  the  canal 
could  be  most  readily  made,  and  the  exact  relations  of 
the  structures  composing  it  felt. 

Dissection. — In  order  to  arrive  at  a  correct  idea  of 
the  parts  concerned  in  inguinal  hernia,  it  is  advisable 
to  endeavor  to  obtain  a  simultaneous  view  of  both  sur- 
faces of  the  abdominal  parietes  in  this  region,  and  for 
this  purpose  a  flap  containing  the  entire  thickness  of 
the  walls  should  be  made  (including  the  umbilicus),  so 
that  in  prosecuting  the  dissection  the  actual  relation 
of  the  structures  both  at  the  commencement  and  termi- 
nation of  the  course  taken  by  a  hernia  may  be  examined 
with  facility. 

On  reflecting  the  skin,  the  superficial  fascia  is  readily 
divisible  into  two  layers,  between  which  lie  the  cutane- 
ous vessels  and  lymphatics,  the  deep  layer  being  closely 

15 


174 


SURGICAL    ANATOMY    OF 


attached  to  Poupart's  .ligament  and  to  the  crest  of  the 
ilium.     This  fascia  is  freely  movable  over  the  subjacent 


FIG.  25. 


Superficial  dissection  of  the  inguinal  and  femoral  regions,  a.  Superficial 
layer  of  fascia  (reflected),  b.  Deeper  layer  of  fascia  (reflected),  the  superficial 
vessels  being  left  attached  to  the  external  oblique,  c.  Inguinal  lymphatic  glands. 
d.  Superficial  circumflex  iliac  artery,  e.  Superficial  epigastric  artery.  /.  Supe- 
rior external  pudic  artery,  g.'  Poupart's  ligament,  h.  Intercolumnar  fascia. 
i.  External  abdominal  ring.  k.  Arciform  fibres  of  external  oblique.  I.  Inter- 
nal saphena  vein.  m.  Femoral  lymphatic  glands,  n.  Ilio-inguinal  nerve,  o. 
Saphenous  opening.  (From  WOOD,  on  Rupture.) 

aponeurosis,  a  circumstance  which  is  taken  advantage  of 
by  the  surgeon  in  making  his  incisions  down  upon  a 


THE    INGUINAL    REGION.  175 

strangulated  hernia,  when,  owing  to  this  laxity,  by 
pinching  up  a  fold  of  integument  and  transfixing  it,  he 
obtains  a  linear  incision,  which  does  not  include  either 
sac  or  gut.  It  is,  moreover,  of  great  value  for  the  in- 
troduction of  the  needles  in  Wood's  operation  for  the 
radical  cure.  Between  these  layers  of  fascia  are  the  lym- 
phatics, transmitting  the  ducts  from  the  external  genitals, 
the  termination  of  ilio-hypogastric  and  ilio-inguinal 
nerves,  and  three  superficial  branches  of  the  common 
femoral  artery — viz.,  the  superficial  epigastric,  superfi- 
cial circumflex  iliac,  and  superficial  external  pudic,  with 
their  accompanying  veins.  In  plastic  operations  for  the 
relief  of  extroversion  of  the  bladder,  the  superficial  epigas- 
tric should  be  carefully  preserved  to  nourish  the  flaps. 
Beneath  the  deep  layer  of  the  superficial  fascia  is  the  apo- 
neurosis  of  the  external  oblique ;  its  lower  portion,  by  its 
union  with  the  fascia  lata  and  deep  fascia,  forms  the  crural 
arch,  which  extends  from  the  anterior  superior  spine  of  the 
ilium  to  the  spine  of  the  pubes,  having  also  an  attachment 
to  the  ilio-pectineal  line  (Gimbernat's  ligament).  The  at- 
tachment to  the  ilio-pectineal  line  is  strengthened  by  a 
triangular  band  of  fibres  passing  upwards  and  inwards 
towards  the  linea  alba,  behind  the  inner  pillar  of  the  exter- 
nal ring.  It  will  be  noticed  that  extension  and  abduction 
of  the  leg  renders  the  crural  arch  tense,  so  that  in  the  ex- 
amination of  the  parts  or  in  the  application  of  the  taxis, 
the  external  abdominal  ring  must  be  relaxed  by  flexion 
and  abduction.  The  two  pillars  of  the  external  ring  are 
bound  together  by  a  set  of  aponeurotic  fibres,  which  in- 
terlace, more  or  less,  over  the  whole  of  the  inner  part  of 
this  region,  constituting  the  intercolumnar  bands,  from 
which  a  fascia  is  derived,  forming  a  covering  to  the 
emerging  cord — the  intercolumnar  or  external  spermatic 


176  SURGICAL    ANATOMY    OF 

fascia.  It  is  the  weakness  or  giving  way  of  these  bands 
which  favors  the  hernial  protrusion.  The  inner  pillar 
of  the  ring  is  flat  and  riband-shaped,  whilst  the  outer  is 
sickle-shaped  and  thick,  and  upon  it  the  cord  or  round 
ligament  rests.  On  detaching  a  "  dog's  ear"  of  the  apo- 
neurosis  of  the  external  oblique  along  Poupart's  ligament, 
immediately  beneath  it  is  a  cellular  interval  separating 
it  from  the  muscular  fibres  of  the  internal  oblique,  and 
the  conjoined  tendon  of  this  muscle  and  the  transversa- 
lis,  this  latter  passing  in  front  of  the  rectus  and  pyrami- 
dalis  to  the  linea  alba  and  pubes ;  blended  with  the  lower 
fibres  of  the  internal  oblique  and  transversalis  are  the 
fibres  of  the  cremaster  muscle,  on  which  the  ilio-ingui- 
nal  nerve  lies.  On  carefully  detaching  the  muscular 
fibres  of  the  internal  oblique  from  Poupart's  ligament, 
and  reflecting  them  outwards  and  inwards,  the  fibres  of 
the  transversalis  are  met  with,  forming  an  arch  over  the 
cord,  and  beneath  this  arch  is  the  spout-like  prolonga- 
tion of  the  transversalis  fascia  (the  infundibuliform)  in- 
vesting it.  Behind  the  transversalis  and  the  rectus,  is 
the  transversalis  fascia,  closely  lining  them,  and  here 
forming  with  the  subperitoneal  aponeurosis  the  posterior 
layer  of  the  sheath  of  the  latter  muscle ;  in  its  lower 
fourth  it  is  attached  to  the  under  surface  of  the  crural 
arch,  becoming  continuous  with  the  fascia  iliaca.  Be- 
neath this  fascia  is  the  parietal  layer  of  the  peritoneum. 

The  position  of  the  deep  epigastric  vessels  can  be  easily 
seen,  lying  beneath  the  transversalis  fascia  and  the  peri- 
toneum, and  passing  obliquely  upwards  and  inwards,  to 
gain  the  under  surface  of  the  rectus  at  about  its  lower 
third  and  internal  to  the  cord. 

It  will  be  now  found  convenient  to  turn  down  the  flap 
consisting  of  the  entire  thickness  of  the  abdominal  wall 


THE    INGUINAL    REGION. 


177 


as  suggested,  in  order  to  obtain  a  view  of  these  structures 
from  the  peritoneal  surface. 


FIG.  26. 


Dissection  of  the  lower  part  of  the  abdominal  wall  from  within,  the  peritoneum 
having  been  removed,  a.  External  iliac  artery,  b.  Epigastric  artery,  c.  Bor- 
der of  the  posterior  part  of  the  sheath  of  the  rectns  (fold  of  Douglas),  d.  Con- 
joined tendon  in  the  triangle  of  Hesselbach.  e.  Posterior  surface  of  rectus. 
/.  Fascia  transversalis.  g.  Vas  deferens.  h.  Spermatic  vessels,  i.  Obliterated 
hypogastric  artery.  A.  Lymphatics  in  crural  rings.  I.  Internal  abdominal  ring. 
(From  WOOD,  on  Rupture.) 

The  position  of  the  internal  abdominal  ring  is  recog- 
nized as  a  dimple-like  depression  in  the  peritoneum,  in- 
dicating the  closure  of  its  vaginal  process.  Below  this 


178  SURGICAL    ANATOMY    OF 

is  a  furrow  showing  the  position  of  Potipart's  ligament, 
and  below  this  again  a  depression  over  the  crural  ring. 

The  cords  of  the  obliterated  hypogastric  arteries  are 
seen  as  ridges,  passing  upwards  towards  the  umbilicus, 
forming  the  margins  of  the  superior  false  ligaments  of 
the  bladder,  and  between  them  lie  the  remains  of  the 
urachus.  On  stripping  off  the  peritoneum,  the  loose 
subperitoneal  fascia  is  seen,  in  which  lie  the  deep  epigas- 
tric and  circumflex  ilii  vessels,  the  latter  running  along 
the  deep  surface  of  the  crural  arch. 

Parts  concerned  in  Inguinal  Hernia. — Inguinal  hernia 
is  described  as  being  oblique  or  direct,  with  reference  to 
the  inguinal  canal ;  and  external  or  internal,  with  refer- 
ence to  its  position  to  the  deep  epigastric  vessels. 

The  inguinal  canal  is  an  oblique  channel,  about  an 
inch  and  a  half  long  in  the  male,  and  about  two  inches 
in  the  female,  owing  to  the  greater  breadth  of  the  pelvis, 
and  its  openings  are  the  internal  and  external  abdominal 
rings ;  and  ike  relation  of  the  internal  or  deep  ring  to  the 
surface  is  indicated  by  a  point  taken  about  half  or 
tliree-quarters  of  an  inch  above  the  centre  of  Poupart's 
ligament,  along  a  line  at  right  angles  to  it.  This  inter- 
nal ring  is  an  oval  opening  in  the  fascia  transversalis, 
transmitting  the  cord  in  the  male  and  the  round  liga- 
ment in  the  female,  and  is  bounded  above  and  exter- 
nally by  the  arched  fibres  of  the  transversalis  muscle, 
and  internally  by  the  deep  epigastric  vessels. 

The  boundaries  of  the  inguinal  canal  are,  in  front,  the 
integument  and  superficial  fascia,  the  aponeurosis  of 
external  oblique,  the  internal  oblique  for  its  outer  third, 
and  a  small  portion  of  the  cremaster.  Behind,  the  con- 
joined tendon,  triangular  fascia,  transversalis  fascia, 
subperitoneal  fat,  and  peritoneum.  Above,  the  fibres  of 


THE    INGUINAL    REGION. 


179 


the  internal  oblique  and  transversalis ;  and  below,  Pou- 
part's  ligament  and  the  fascia  transversalis. 


FIG.  27. 


Dissection  of  the  inguinal  canal,  a.  External  oblique  (turned  down),  b,  b. 
Internal  qblique.  c.  Transversalis.  d.  Conjoined  tendon,  e.  Rectus  abdomi- 
nis,  with  sheath  opened.  /.  Fascia  transversalis.  g.  Triangular  fascia,  h.  Cre- 
master.  i.  Infundibular  fascia.  (From  WOOD,  on  Rupture.) 

Oblique  or  external  inguinal  hernia  follows  the  course 
of  the  spermatic  cord  or  round  ligament,  passing  through 
both  rings. 

The  coverings  of  an  oblique  inguinal  hernia  are  the 


180 


SURGICAL    ANATOMY    OF 


same  as  those  of  the  cord — viz.,  from  without  inwards  : 
(1.)  Integument.  (2.)  Superficial  fascia.  (3.)  Interco- 
lumnar  fascia.  (4.)  Cremaster  muscle.  (5.)  Infundibu- 
liform  fascia.  (6.)  Subserous  cellular  tissue.  (7.)  Peri- 
toneum (sac).  If  the  intestine  passes  into  the  scrotum, 
it  is  called  complete;  if  retained  in  the  canal,  incomplete, 
or  bubonocele. 

In  cases  of  strangulation,  the  constriction  is  due  to 
some  portion  of  either  of  the  rings,  or  if  in  the  canal,  to 
the  fibres  of  the  internal  oblique  or  transversalis,  and 
any  incision  for  the  relief  of  the  stricture  should  be 
made  upwards,  to  avoid  wounding  the  deep  epigastric 
vessels  or  spermatic  cord,  which  in  this  form  of  hernia 
lie,  the  former  to  the  inside  of  the  neck  of  the  sac,  and 
the  latter  directly  behind  it. 


FIG.  28. 


FIG.  29. 


FIG.  28  — Diagram  of  a  congenital  hernia,  the  sac  being  continuous  with  the 
tunica  vaginalis  testis.  (HEATH.) 

FIG.  29.— Diagram  of  an  infantile  hernia,  showing  the  tunica  vaginalis  pro- 
longed in  front  of  the  sac.  (HEATH.) 

Varieties. — Oblique  inguinal  hernia  is  liable  to  varie- 
ties, known  as  congenital,  infantile,  and  encysted.  In 
the  congenital  form,  the  pouch  of  peritoneum  which  ac- 


THE    INGUINAL    REGION.  181 

companies  the  cord  and  testis  in  its  descent  during  foetal 
life  remains  patent,  and  the  gut  falls  into  this  pouch, 
and  thus  lies  in  contact  with  the  testicle.  (In  congenital 
hydrocele  the  condition  of  the  parts  is  the  same.) 

In  the  infantile  form,  the  peritoneal  pouch  is  only 
partially  obliterated,  and  the  sac  descends  along  the  in- 
guinal canal  into  the  scrotum,  behind  the  pouch ;  hence 
there  are  three  layers  of  peritoneum  in  front  of  the  gut 
and  its  proper  investment — viz.,  two  of  the  tunica  vagi- 
nalis  testis,  and  the  sac  itself. 

Direct  or  internal  inguinal  hernia  differs  in  its  course 
from  oblique,  in  not  passing  through  the  inner  ring,  but 
through  the  space  known  as  the  triangle  of  Hesselbach, 
the  boundaries  of  which  are, — externally,  the  epigastric- 
artery  ;  internally,  the  outer  edge  of  the  rectus,  and  infe- 
riority. Poupart's  ligament.  This  space  is  filled  in  on  its 
inner  two-thirds  by.  the  conjoined  tendon,  and  for  the 
rest  by  the  fascia  transversalis.  Any  hernial  protrusion 
through  this  interval  and  emerging  from  the  external 
ring,  would  have  the  deep  epigastric  artery  external  to 
its  sac,  and  the  spermatic  cord  internal  and  posterior. 
This  form  of  rupture  may  either  force  its  way  through 
the  conjoined  tendon,  or  push  it  before  it. 

Coverings  of  Direct  Inguinal  Hernia. — The  same  as 
those  already  given  in  the  case  of  the  oblique  variety, 
with  the  exception  that  the  conjoined  tendon  takes  the 
place  of  the  cremaster,  the  infundibuliform  fascia  being 
replaced  by  that  portion  of  the  fascia  transversalis  be- 
hind or  immediately  contiguous  to  the  conjoined  tendon- 

The  seat  of  stricture,  in  strangulation,  is  either  at  the 
neck  of  the  sac,  at  the  external  ring,  or  is  due  to  the 
fissured  edges  of  the  conjoined  tendon.  The  incision  for 
its  relief  is  to  be  made  upwards. 

16 


182  SURGICAL    ANATOMY    OF 

The  parts  divided  in  an  operation  for  strangulated  in- 
guinal hernia,  would  be  those  between  the  outer  ring 
and  the  gut,  and  the  sac,  if  so  indicated  by  the  nature 
of  the  case,  and  when  reached,  the  constriction  itself; 
although  in  actual  practice,  the  condition  of  these  struc- 
tures is  often  so  altered  that  this  arrangement  must  be 
merely  regarded  as  anatomical. 

Structures  to  be  Avoided. — The  deep  epigastric  vessels 
and  the  cord. 

The  position  of  the  deep  epigastric  artery  with  regard 
to  the  abdominal  parietes  is  pretty  much  that  of  the  su- 
perficial epigastric  vessels  seen  beneath  the  integuments, 
and  its  course  is  indicated  by  a  line  drawn  from  a  point 
a  little  internal  to  the  centre  of  Poupart's  ligament  to 
about  the  middle  of  the  space  between  the  umbilicus  and 
pubes. 

SUKGICAL  ANATOMY  OF  THE  CKUKAL  KEGION. 

In  works  on  Descriptive  Anatomy,  this  region  is 
generally  described  and  dissected  as  belonging  to  the 
lower  limb ;  but  as  its  surgical  relations  essentially  con- 
cern those  of  the  contents  of  the  abdomen,  and  as  it  has 
so  many  points  in  common  with  it,  besides  forming,  by 
its  deep  aspect,  part  of  the  abdominal  parietes,  it  has 
been  thought  advisable  to  introduce  it  here,  and  to  refer 
back  to  it  again  when  describing  the  superior  femoral 
region. 

The  boundaries  of  this  region  are, — above,  the  crural 
arch;  externally,  a  line  passing  from  the  anterior  iliac 
spine  to  the  trochanter  major  ;  internally,  the  prominence 
of  the  adductor  longus  ;  and  below,  a  line  drawn  through 
the  point  of  meeting  of  the  sartorius  and  adductors. 


THE    CRURAL    REGION.  183 

These  several  muscular  eminences  inclose  an  irregular 
triangular  space,  sloping  towards  the  centre,  in  which 
lie  the  common  femoral  vessels ;  it  is  the  seat  of  crural 
or  femoral  hernia,  which  appears  at  the  inner  and  upper 
part. 

Dissection. — An  incision  skin  deep  is  to  be  made 
along  Poupart's  ligament,  met  by  one  along  the  outer 
border  of  the  adductor  longus,  and  the  flap  turned  down 
towards  the  sartorius.  The  superficial  layer  of  superfi- 
cial fascia  is  first  met  with,  continuous  with  that  over 
the  abdomen,  containing  a  good  deal  of  fat,  in  which  lie 
the  superficial  circumflexa  ilii,  epigastric  and  external 
pudic  vessels ;  filaments  from  the  external,  internal,  and 
middle  cutaneous,  crural  and  ilio-inguinal  nerves,  lym- 
phatic glands,  and  ducts.  It  will  be  noticed  that  the 
lower  chain  of  the  lymphatic  ganglia  in  the  axis  of  the 
thigh  and  the  glands  are  those  which  become  enlarged 
in  ulcers  or  injuries  of  the  lower  limb,  whilst  the  upper 
series,  which  lie  in  the  fold  of  the  groin,  receive  the 
lymphatics  of  the  genital  organs,  and  become  affected  in 
venereal  complaints.  On  removing  this  layer,  the  deep- 
portion  of  the  superficial  fascia  is  met  with  attached  to 
Poupart's  ligament,  and  to  the  margins  of  the  saphe- 
nous  opening,  forming  a  spout-like  prolongation  over 
the  internal  saphena  vein  as  it  lies  in  this  opening. 
That  portion  of  the  superficial  fascia  which  closes  in  the 
saphenic  opening,  is  called  the  cribriform  fascia,  from 
its  numerous  perforations,  due  to  the  passage  of  lym- 
phatic ducts  and  the  superficial  vessels  already  named. 
When  this  fascia  has  been  removed,  the  fascia  lota  is 
next  seen,  a  dense  aponeurotic  structure,  attached  by  an 
outer  or  iliac  portion  to  the  crest  and  anterior  spine  of 
the  ilium  ;  and  blended  with  the  lower  edge  of  Poupart's 


184  SURGICAL    ANATOMY    OF 

ligament  to  the  spine  of  the  pubes  and  the  ilio-pectineal 
line,  where  it  unites  with  Gimbernat's  ligament.  This 
portion  of  the  fascia  lata  forms  a  falciform  process  which 
passes  in  front  of  the  sheath  of  the  vessels,  and  is  the 
outer  pillar  of  the  saphenic  opening.  The  inner  portion, 
or  pubic,  is  attached  along  the  inferior  outlet  of  the  pel- 
vis, and  is  there  connected  with  the  perinea!  fasciae  and 
penis,  and  passing  behind  the  femoral  vessels,  becomes 
attached  to  the  ilio-pectineal  line,  being  thus  connected 
with  Gimbernat's  ligament,  the  falciform  process  of  the 
iliac  portion,  the  fascia  iliaca,  and  the  capsule  of  the  hip- 
joint.  It  is  through  this  opening  that  the  internal  sa- 
phena  vein  passes  to  join  the  common  femoral  vein. 

The  fascia  lata  attached  along  Poupart's  ligament  is 
next  to  be  detached  and  turned  down,  when  the  anterior 
layer  of  the  sheath  of  the  vessels  is  brought  into  view, 
which  is  a  process  of  the  fascia  transversalis,  and  emerges 
from  beneath  the  crural  arch.  The  posterior  portion  of 
this  sheath  is  formed  by  the  fascia  iliaca,  and  it  will  be 
seen  that  it  occupies  the  space  between  the  psoas  muscle 
and  Gimbernat's  ligament.  If  the  crural  arch  be  pulled 
upwards  a  dense  band  of  fibres  will  be  seen  connecting 
the  upper  layer  of  the  sheath  with  the  crural  arch,  and 
reaching  from  the  psoas  to  Gimbernat's  ligament  and 
the  conjoined  tendon.  This  is  the  deep  crural  arch.  If 
now  three  vertical  slits  be  made  into  the  sheath,  one 
over  the  course  of  the  artery  externally,  another  over 
the  femoral  vein,  centrally,  and  a  third  a  little  internal 
to  the  course  of  the  vein,  the  sheath  will  be  found  to  be 
divided  into  three  compartments,  separated  by  distinct 
processes.  The  inner  compartment  is  termed  the  crural 
canal.  The  interval  between  the  femoral  vein  in  its 
compartment  and  the  curved  edge  of  Gimbernat's  liga- 


THE    CRURAL    REGION. 


185 


ment  is  the  crural  ring,  the  other  boundaries  of  which 
are — above,  the  deep  crural  arch ;  behind,  ilio-pectineal 
line,  origin  of  pectineus,  and  attachment  of  pubic  por- 
tion of  fascia  lata.  On  passing  the  finger  into  the  crural 


FIG.  30. 


Crural  sheath  laid  open.  a.  Middle  cutaneous  nerve,  c.  Placed  to  the  inner 
side  of  Gimbernat's  ligament,  d.  Iliac  portion  of  fascia  lata.  e.  Pubic  portion  of 
fascia  lata.  /.  Margin  of  saphenous  opening  (turned  back),  k.  Femoral  sheath 
opened  by  three  incisions.  1.  Saphena  vein.  (From  WOOD,  on  Rupture.) 


ring,  the  inferior  portion  of  Gimbernat's  ligament  can 
be  felt  along  the  ilio-pectineal  line,  considerably  behind 
the  ring.  The  crural  ring  is  blocked  in  above  by  a  thin 
fascia  derived  from  the  subperitoneal,  termed  the  septum 
crurale,  which  transmits  ducts  of  glands.  The  crural 
canal  is  usually  occupied  by  a  lymphatic  gland. 

In  the  employment  of  taxis  for  the  reduction  of  a 


186  SURGICAL    ANATOMY    OF 

crural  hernia,  it  must  be  remembered  that  the  direction 
of  the  crural  canal  is  downwards,  and  slightly  forwards 
and  outwards  ;  moreover,  that,  in  order  to  relax  the  ori- 
fices of  this  canal,  the  thigh  must  be  flexed  upon  the 
pelvis,  adducted  and  rotated  inwards. 

The  course  taken  by  a  crural  hernia  is  as  follows : 
First,  passing  into  the  femoral  ring,  it  descends  verti- 
cally in  the  femoral  canal  as  far  as  the  saphenic  opening ; 
next,  being  here  prevented  from  passing  further  along 

FIG.  31. 


Section  of  the  structures  which  pass  beneath  the  femoral  arch.  1.  Poupart's 
ligament.  2,  2.  Iliac  portion  of  the  fascia  lata,  attached  along  the  margin  of  the 
crest  of  the  ilium,  and  along  Poupart's  ligament  as  far  as  the  spine  of  the  pubes 
(3).  4.  Pubic  portion  of  the  fascia  lata,  continuous  at  3  with  the  iliac  portion, 
and  passing  outwards  behind  the  sheath  of  the  femoral  vessels  to  its  outer  border 
at  5,  where  it  divides  into  two  layers  ;  one  is  continuous  with  the  sheath  of  the 
psoas  (6)  and  iliacus  (7) ;  the  other  (8)  is  lost  upon  the  capsule  of  the  hip-joint 
(9).  10.  The  anterior  crural  nerve.  11.  Gimbernat's  ligament.  12.  The  femoral 
ring  within  the  femoral  sheath.  13.  Femoral  vein.  14.  Femoral  artery;  the 
two  vessels  and  the  ring  are  surrounded  by  the  femoral  sheath.  (From  WILSON.) 

the  sheath  of  the  vessels,  it  is  directed  forwards  and 
subsequently  upwards,  upon  the  external  pillar  of  the 
opening  and  Poupart's  ligament. 


THE    CRURAL    REGION.  187 

The  coverings  of  a  crural  hernia  are — sac,  subserous 
areolar  tissue,  septum  crurale,  sheath  of  vessels,  cribri- 
form fascia,  superficial  fascia,  and  integuments. 

The  seat  of  stricture  may  either  be  the  sac  itself,  or 
the  junction  of  the  falciform  process  with  Gimbernat's 
ligament,  or  the  outer  margin  of  the  opening ;  and  in 
dividing  the  obstruction,  the  incision  is  to  be  made  up- 
wards and  inwards. 

An  irregular  course  of  the  obturator  artery  bears  a 
very  important  relation  to  the  crural  ring,  should  it 
arise  by  a  common  trunk  with  the  deep  epigastric,  and 
when  it  courses  along  the  border  of  Gimbernat's  liga- 
ment, in  order  to  gain  the  thyroid  foramen.  In  this 
case  the  neck  of  the  hernia  would  be  surrounded  by  an 
arterial  ring,  and  in  an  operation  for  the  relief  of  stran- 


7 

Irregular  course  of  obturator  artery. 


gulation,  might  run  great  risk  of  being  wounded.  Prac- 
tically, however,  it  would  probably  recede,  unless  the 
knife  were  roughly  pushed  past  the  posterior  aspect  of 
the  ring. 


188  SURGICAL    ANATOMY    OF    THE 

Besides  hernise,  the  fold  of  the  groin  is  the  seat  of 
other  tumors,  of  which  an  accurate  knowledge  of  the 
anatomy  of  the  region  affords  the  chief  help  towards  the 
diagnosis ;  such  as  aneurism,  the  pointing  of  a  psoas 
abscess,  an  inflamed  lymphatic  gland,  cysts,  enlargement 
of  the  bursa3  beneath  the  tendon  of  the  psoas,  which  is 
often  connected  with  the  hip-joint. 

Artificial  Anus. — In  cases  of  strangulated  hernia, 
whether  inguinal  or  crural,  when  the  bowel  has  become 


FIG.  33. 


Sketch  of  artificial  anus. 
1.  Mesentery.    2.  Eperon.    3.  Opening  of  artificial  anus. 

gangrenous,  or  if  the  intestine  has  been  wounded,  and 
given  way  in  a  state  of  gangrene,  surgical  principles  in- 
dicate the  removal  of  this  portion,  and  the  subsequent 
formation  of  an  artificial  anus,  and  the  following  condi- 
tion generally  results,  which  explains  the  impediments 
in  the  way  of  its  healing  :  The  edges  of  the  gut  become 
attached  to  the  aperture  in  the  abdominal  wall,  and  that 
generally  at  an  angle  which  soon  becomes  acute.  As  the 
upper  portion  of  the  intestine  only  transmits  faeces,  the 
lower  remains  as  a  useless  tube,  and  consequently  con- 
tracts in  its  calibre.  That  portion  of  the  bowel  to  which 
the  mesentery  is  attached,  becomes  drawn  out  into  a 
spur-like  process  (eperon) ;  which  acting  as  a  valve,  serves 


ILIAC  FOSSA  (EXTRA-PERITONEAL).        189 

to  direct  the  faeces  out  of  the  body,  but  not  on  into  their 
proper  channel. 


SUEGICAL  ANATOMY  OF  THE  ILIAC  FOSSA 
(EXTRA-PEK1TONEAL). 

The  iliac  fossa  forms  the  inner  aspect  of  the  region 
just  described,  and  is  of  great  surgical  interest.  From 
within  outwards  the  structures  successively  met  with 
are,  the  peritoneum,  the  subperitoneal  fat  and  cellular 
tissue,  which  contains  a  large  amount  of  fat,  allowing 
the  peritoneum  to  be  readily  stripped  off,  in  ligature 
of  the  vessels,  the  common  and  external  iliac  arteries 
and  their  veins,  the  fascia  iliaca,  which  is  a  continuation 
of  the  fascia  transversalis,  and  has  attachments  to  the 
crest  of  the  ilium,  Poupart's  ligament,  and  vertebral 
column.  Beneath  the  fascia  are  the  circumflex  ilii  ar- 
tery and  veins,  the  iliacus  and  psoas  muscles,  in  the 
substance  of  which  is  the  anterior  crural  nerve ;  upon 
the  former  muscle  are  seen  the  external  cutaneous  and 
the  ilio-inguinal,  and  upon  the  latter  the  genito-crural 
nerves,  and  the  nutrient  vessels  derived  from  the  ilio- 
1  urn  bar. 

The  chief  points  of  surgical  importance  refer  to  liga- 
ture of  the  vessels,  the  common  and  external  iliac  arte- 
ries, and  abscesses. 

The  Common  Iliac. — The  course  taken  by  this  vessel, 
with  regard  to  the  surface  of  the  body,  is  from  a  point 
to  the  left  of  the  umbilicus,  and  in  a  line  with  the  iliac 
crests  and  the  centre  of  Poupart's  ligament.  After  the 
intestines  and  peritoneum  have  been  raised,  it  will  be 
seen  that  the  aorta  bifurcates,  or  does  generally,  on  the 
left  side  of  the  fourth  lumbar  vertebra,  consequently  the 


190  SURGICAL    ANATOMY    OF    THE 

vessels  of  the  right  and  left  side  differ  somewhat  in 
length,  the  right  being  slightly  the  longer,  and  lies 
rather  more  obliquely  across  the  body  of  the  fifth  lum- 
bar vertebra.  Their  length  is  about  two  inches,  more 
or  less,  and  passing  downwards  and  outwards,  at  the 
sacro-iliac  synchondrosis  divide  into  external  and  inter- 
nal iliacs ;  the  vena  cava  inferior  lying  to  the  right  side, 
and  being  formed  by  the  union  of  the  two  common  iliac 
veins,  the  right  common  iliac  artery  crosses  their  junc- 
tion, rendering  the  relation  of  the  vessels  on  the  right 
side  more  intimate,  the  vein  projecting  externally  to  the 
artery  above,  and  being  internal  to  it  below,  whilst  on 
the  left  side  the  vein  lies  below  and  internal  to  its  artery. 
Both  are  crossed  at  their  bifurcation  by  the  ureter. 

The  relations  of  the  common  iliac  of  the  right  side :  In 
front  of  it,  the  peritoneum,  ilium,  sympathetic  plexus, 
and  ureter;  externally ',  the  cava,  right  common  iliac 
vein,  psoas  magnus ;  behind,  junction  of  common  iliac 
veins,  obturator  nerve.  On  the  left  side  it  has,  in  front, 
peritoneum,  sympathetic,  rectum,  inferior  meseuteric 
artery,  ureter ;  externally,  psoas  magnus ;  internally,  left 
common  iliac  vein ;  behind,  left  common  iliac  vein,  ob- 
turator nerve. 

Ligature  of  Common  Iliac  Artery. — In  order  to  reach 
this  vessel  a  curved  incision  is  recommended,  commenc- 
ing from  just  above  the  middle  of  Poupart's  ligament  to 
a  point  an  inch  or  so  above  and  to  the  inner  side  of  the 
anterior  superior  spine,  or,  commencing  from  a  point 
close  to  the  anterior  superior  spine,  towards  the  edge  of 
the  rectus.  The  first  incision  divides  the  integuments ; 
next  the  external  oblique,  the  internal  oblique,  and  the 
transversal  is  are  to  be  divided  in  succession  and  to  an 
equal  extent.  Beneath  this  latter  is  the  transversal  is 


ILIAC  FOSSA  (EXTRA-PERITONEAL).         191 

fascia,  which  is  to  be  carefully  pinched  up,  nicked,  and 
a  director  insinuated  between  it  and  the  peritoneum.  It 
is  then  to  be  divided  to  the  length  of  the  incision  in  the 
muscles  (the  deep  circumflex  iliac  artery  will  stand  a 
chance  of  being  cut).  The  peritoneal  bag  and  its  con- 
tents are  to  be  then  pulled  away  towards  the  middle 
line,  when  the  vessel  will  be  seen  just  beyond  the  sacro- 
iliac  synchondrosis.  The  needle  is  to  be  passed  from 
within  outwards. 

The  collateral  circulation  would  be  maintained  by  the 
inosculation  of  the  lateral  sacral  and  middle  sacral,  epi- 
gastric and  internal  mammary,  aortic  intercostals  and 
lumbar,  the  ilio-lumbar  and  last  lumbar,  the  obturator, 
with  its  fellow  of  the  opposite  side,  and  the  epigastric, 
gluteal,  and  sacral,  hsemorrhoidal  of  the  internal  iliac, 
with  the  superior  hsemorrhoidal  of  the  inferior  mesen- 
teric  and  the  vesical  of  the  opposite  sides,  and  the  uterine 
and  ovarian  in  the  female. 

The  External  Iliac  Artery. — The  course  of  this  vessel 
would  be  indicated  on  the  surface  of  the  body  by  a  line 
extending  from  either  side  of  the  umbilicus  to  the  centre 
of  Poupart's  ligament.  It  commences  at  the  bifurcation 
of  the  common  iliac,  and  extends  to  the  crural  arch, 
where  it  becomes  common  femoral. 

Its  relations  are, — in  front,  intestines  and  peritoneum, 
a  considerable  quantity  of  loose  areolar  tissue,  the  sper- 
matic vessels,  the  genito-crural  nerve  (near  Poupart's 
ligament),  the  circumflexa  ilii  vein,  and  a  chain  of  lym- 
phatics ;  externally,  the  psoas  muscle,  and  fascia  iliaca ; 
internally,  the  external  iliac  vein,  vas  deferens,  and  lym- 
phatics ;  behind,  the  external  iliac  vein  and  psoas  magnus 
muscle. 

Ligature  of  External  Iliac. — An  incision  (curved  for 


192  SURGICAL    ANATOMY    OF 

preference)  is  to  be  made,  commencing  at  the  middle  of 
Poupart's  ligament,  and  at  about  an  inch  above  it,  to  a 
point  just  beyond  the  anterior  superior  spine  of  the 
ilium.  The  structures  divided  and  the  method  of  divid- 
ing them  are  those  described  in  ligature  of  the  common 
iliac,  with  this  exception,  that  here  they  are  more  apo- 
neurotic,  from  being  nearer  Poupart's  ligament ;  and  the 
deep  epigastric  artery  is  in  this  instance  in  danger  of 
division,  if  the  incision  be  made  too  near  the  rectus 
muscle. 

When  the  peritoneum  and  intestines  have  been  pulled 
away  from  the  point  where  the  ligature  is  to  be  applied, 
it  often  happens  that  neither  artery  nor  vein  is  to  be 
found ;  in  this  case  they  have  followed  these  structures, 
and  will  be  discovered  lying  adherent  to  the  under  sur- 
face of  the  peritoneal  bag,  with  the  ureter,  from  which 
they  must  be  cautiously  separated.  The  needle  is  to  be 
applied  from  within  outwards. 

Collateral  Circulation  after  Ligature  of  External  Iliac  : 
The  gluteal  anastomoses,  with  the  external  circumflex 
from  the  profunda  femoris ;  the  ilio-lumbar,  with  the 
circumflexa  ilii ;  the  obturator,  with  the  internal  circum- 
flex from  the  profunda ;  the  ischiatic,  with  the  perforat- 
ing and  circumflex  branches  of  the  profunda ;  the  inter- 
nal pudic,  with  the  superficial  and  deep  external  pudic, 
and  the  internal  circumflex  from  the  profunda ;  and  the 
deep  epigastric  with  the  superior  epigastric  from  the  in- 
ternal mammary. 

SUKGICAL  ANATOMY  OF  THE  LUMBAR  REGION. 

The  lumbar  region  forms  the  posterior  portion  of  the 
abdominal  parietes,  and  is  of  surgical  importance  from 
the  application  to  its  anterior  aspect  of  the  abdominal 


THE    LUMBAR    REGION.  193 

viscera,  and  from  the  numerous  fasciae  which  enter  into 
its  formation,  and  the  relation  of  these  fasciae  to  ab- 
scess, &c. 

The  limits  or  boundaries  of  the  region  may  be  defined 
as  follows  :  above,  the  lower  border  of  the  last  rib;  below, 
the  crest  of  the  ilium  ;  externally,  a  line  drawn  through 
the  end  of  the  first  rib  perpendicularly  to  the  iliac  crest; 
and  internally,  the  line  of  the  spinous  processes  of  the 
vertebrae. 

Dissection. — On  making  a  dissection  of  the  region  in- 
dicated by  these  limits,  from  the  integument  towards  the 
abdominal  cavity  and  its  contents,  the  following  struc- 
tures would  be  met  with :  The  integument,  tough  and 
thick ;  the  subcutaneous  cellular  tissue,  containing  a 
great  deal  of  fat,  excepting  along  the  middle  line ;  the 
aponeurotic  origin  of  the  latissimus  dorsi  and  serratus 
posticus  inferior,  part  of  the  external  oblique,  and  com- 
mon aponeurotic  attachment  of  the  internal  oblique  and 
transversalis,  the  mass  of  the  erector  spinae  muscles,  a 
considerable  number  of  vessels  and  nerves  lying  between 
these  muscles,  the  attachment  to  the  transverse  processes 
of  the  lumbar  vertebras  of  the  middle  lamina  of  the  apo- 
neurosis  of  the  transversalis  muscle,  the  quadratus  lum- 
borum  muscle  and  ilio-lumbar  ligament,  branches  of  the 
lower  part  of  the  dorsal  and  upper  part  of  lumbar  plex- 
uses, psoas  muscles,  transversalis  fascia,  a  large  quantity 
of  fat  and  cellular  tissue  separating  the  kidney  from  the 
parietes,  the  kidney  itself,  with  the  ureter  and  spermatic 
or  ovarian  vessels,  and  in  the  front  of  the  psoas,  the 
colon,  the  ascending  on  the  right,  and  the  descending  on 
the  left.  The  ascending  colon  is  generally  inclosed  in 
peritoneum,  which  forms,  by  its  attachment  to  the  spine, 
a  mesocolon,  whilst  the  descending  is  covered  only 


194  SURGICAL    ANATOMY    OF 

anteriorly  and  laterally,  and  is  for  that  reason  selected 
for  the  operation  of  opening  the  colon  in  the  left  loin 
(Amussat). 

That  portion  of  the  spinal  column  which  is  inclosed 
between  these  regions,  has  upon  its  anterior  surface  the 
crura  of  the  diaphragm,  covered  by  peritoneum  and  sub- 
peritoneal  fat  and  fascia,  the  vena  cava  ascendens,  ab- 
dominal aorta,  and  on  either  side  the  chain  of  the  sym- 
pathetic, the  thoracic  duct,  the  receptaculum  chyli,  vena 
azygos  major,  and  a  large  number  of  lymphatic  ganglia. 

Lumbar  Colotomy. — The  colon  may  be  reached  either 
by  a  transverse  incision  (Amussat),  or  by  a  longitudinal 
one  (Hilton,  Callisen). 

Structures  divided  in  Amussafs  Operation. — A  point  is 
taken  midway  between  the  crest  of  the  ilium  and  the 
last  rib  at  the  outer  edge  of  the  erector  spinae,  varying 
in  length  according  to  the  development  of  the  individual, 
and  is  directed  outwards,  at  first  dividing  the  integu- 
ments, the  aponeurotic  origin  of  the  latissimus  dorsi,  and 
some  few  fibres  of  the  external  oblique ;  next  the  origin 
of  the  internal  oblique  and  transversal  is,  and  a  portion 
of  the  quadratus  lumborum  and  its  fascial  investment. 
After  the  transversalis  fascia  has  been  divided,  a  quantity 
of  loose  cellular  tissue  and  fat  is  seen,  which,  being 
scratched  through,  exposes  the  colon.  During  life,  how- 
ever, the  distension  is  generally  so  great  that  the  bowel 
bulges  into  the  wound. 

In  the  vertical  incision,  which  is  •  made  about  four 
inches  or  so  external  to  the  spinous  processes  of  the  ver- 
tebra?, the  structures  divided  would  be,  the  integument, 
the  aponeurotic  origin  of  the  latissimus  dorsi,  the  origin 
of  the  internal  oblique,  tendon,  transversalis  and  trans- 


THE    LUMBAR    REGION.  195 

versalis  fascia.     The  kidney  may  be  mistaken  for  the 
contents  of  the  bowel. 

Lumbar  Fascia. — The  peculiar  arrangement  of  the 
fasciae  in  the  lumbar  region  is  of  great  importance  sur- 
gically, from  the  control  it  has  over  the  course  taken  by 
the  pus  in  lumbar  abscess.  This  fascia  is  the  posterior 
aponeurotic  portion  of  the  transversalis,  and  posteriorly 
gives  attachment  to  the  internal  and  external  oblique 


..3 


Arrangement  of  lumbar  aponeurosis  at  level  of  third  lumbar  vertebra.  1. 
Sacro-lumbalis.  2.  Psoas  magnus.  3.  Longissimus  dorsi.  4.  Quadratus  lumbo- 
rum.  5.  Latissimus  dorsi.  6.  External  oblique.  7.  Internal  oblique.  8.  Trans- 
versalis.  9.  Rectus. 


and  latissimus  dorsi  muscles.  From  its  inner  edge,  two 
laminae,  derived  from  it,  are  attached  to  the  transverse 
processes  of  the  lumbar  vertebrae,  and  inclose  the  quad- 
ratus  lumborum,  the  posterior  lamina  separating  it  from 
the  erector  spinae,  whilst  the  posterior  portion  of  the 


196          SURGICAL    ANATOMY    OF    THE    PELVIS. 

erector  spinse  is  covered  in  by  the  aponeurosis  of  the 
latissimus  dorsi. 

In  spinal  caries  of  the  lumbar  region,  the  pus,  by 
perforating  the  quadratus  lumborum,  between  the  last 
rib  and  crest  of  ilium,  passes  backwards,  and  being 
bound  down  by  the  various  fascial  laminae  just  men- 
tioned, forms  a  tumor,  usually  flat,  broad,  and  slightly 
elevated ;  occasionally  the  pus  finds  its  way  between  the 
abdominal  muscles  and  points  above  Poupart's  ligament. 

Although  the  psoas  muscles  essentially  belong  to  the 
lumbar  region,  yet  psoas  abscesses  do  not  necessarily 
arise  in  them,  the  course  taken  by  the  pus  being  in  a 
great  measure  governed  by  the  fascial  investment  they 
obtain  there ;  this  investment  is  that  of  the  fascia  iliaca, 
which,  as  regards  the  muscles,  is  attached  above  to  the 
ligamenta  arcuata  interna,  internally  to  the  sacrum, 
being  continued  over  the  muscles  to  the  crural  arches, 
beneath  which  the  pus  gravitates,  and  ultimately  points 
external  to  the  femoral  vessels.  Sometimes  it  passes 
through  the  sacro-sciatic  notch  to  the  nates. 

The  relation  of  the  nerves  to  the  spinal  column, 
emerging  as  they  do  either  through  the  intervertebral 
spaces  or  sacral  foramina,  readily  accounts  for  the  course 
taken  by  the  pus  in  these  abscesses. 

Iliac  abscess  is  a  collection  of  matter  either  in  the 
cellular  tissue,  between  the  iliac  fascia  and  peritoneum, 
or  between  the  fascia  iliaca  and  iliacus  muscle,  and  points 
above  Poupart's  ligament,  near  the  anterior  superior 
spinous  process  of  the  ilium. 

SUKGICAL  ANATOMY  OF  THE  PELVIS. 

Those  portions  of  the  true  pelvis  and  its  contents 
which  come  within  the  province  of  the  surgeon  are  more 


EXTERIOR    OF    PELVIS,    ETC.  197 

particularly,  the  genito-urinary  apparatus,  the  termina- 
tion of  the  bowel  and  its  inferior  boundary,  the  perineal, 
and  the  anal  regions.  Those  considerations  of  its  anat- 
omy which  more  particularly  concern  the  accoucheur, 
may  be  advantageously  referred  to  special  works  upon 
the  subject,  such  as  its  various  measurements,  &c. 

Its  walls  present  surgically  two  surfaces  for  examina- 
tion, on  either  of  which  operative  proceedings  may  be 
instituted — (1)  An  external,  partly  free,  consisting  infe- 
riorly  of  the  perineum,  laterally  of  a  region  belonging 
partially  to  the  lower  limb,  and  posteriorly,  of  the  sacral 
and  coccygeal  region  ;  and  (2)  an  internal,  consisting  of 
the  peritoneal  surface  of  the  perineum,  and  soft  parts 
lining  its  bony  structure,  which  include  the  pelvic  vis- 
cera and  the  great  vessels. 

The  external  genitals  may  be  regarded  as  appendages 
to  the  pelvis,  and  will  be  conveniently  treated  of  before 
entering  upon  its  immediate  anatomy,  and  such  parts  of 
its  lateral  boundary  as  are  evidently  common  to  it  and 
to  the  lower  limb  will  be  included  in  the  description  of 
the  latter. 


EXTERIOR  OF  PELVIS— PELVI-PERINEAL  REGION. 
SURGICAL  ANATOMY  OF  THE  SCROTUM. 

Structure. — The  various  tissues  entering  into  the  struc- 
ture of  the  scrotum  are  met  with  on  dissection  in  the 
following  order :  The  skin,  very  thin,  lax,  and  rugose ; 
the  superficial  fascia,  with  which  it  is  closely  associated, 
continuous  with  that  covering  the  abdomen  and  peri- 
neum, and  is  in  this  region  entirely  destitute  of  fat. 
The  dartos,  consisting  of  loose  areolar  tissue,  in  which  is 
a  considerable  amount  of  unstriped  muscular  fibre,  very 

17 


198  EXTERIOR    OF    PELVIS,    ETC. 

vascular,  is  continuous  with  the  superficial  fascia  of  the 
crural  region  and  perineum,  and  sends  a  septum  inwards 
which  divides  the  scrotal  bag  into  two  cavities,  thus  sep- 
arating the  testes.  The  dartos  is  connected  with  the 
subjacent  parts  by  delicate  areolar  tissue,  allowing  of  the 
free  movement  of  the  scrotal  structures  over  the  testes, 
and  owing  to  the  corrugating  power  it  has  over  the  scro- 
tal tissues,  it  is  difficult  to  approximate  the  edges  of  in- 
cisions when  made  in  its  structure.  A  fibro-ceUular  coat 


FIG.  35. 


4 

5 


Tissues  forming  the  scrotum.  1.  Fibres  of  external  oblique.  2.  Dartos.  3. 
Fibrous  tunic.  4.  Skin.  5.  Superficial  fascia.  6.  Dartos,  forming  septnru  be- 
tween the  testes. 


has  been  described,  which  is  the  continuation  of  the  ex- 
ternal spermatic  fascia,  but  it  is  very  thin,  and  not  easily 
followed  beyond  the  cord.  Beneath  this  layer  is  the 
cremasteric  fascia,  derived  from  the  lower  border  of  the 
internal  oblique  and  gubernaculum  during  the  descent 


EXTERIOR    OF    PELVIS,   ETC.  199 

of  the  testis,  and  the  fascia  propria  or  infundibuliform, 
a  derivative  of  the  fascia  transversalis.  All  these  struc- 
tures are  interunited  by  a  very  lax  cellular  tissue,  which 
not  only  allows  of  their  free  movement  over  each  other, 
but  over  the  cord  and  testis. 

The  scrotal  tissues  are  not  very  sensitive,  and  have 
not  much  vitality ;  consequently  in  erysipelatous  inflam- 
mation or  urinary  extravasation  they  rapidly  become 
gangrenous.  When  the  urethra  gives  way  from  unre- 
lieved retention,  or  from  ulceration  of  its  walls,  the  urine 
is  driven  by  the  sudden  contraction  of  the  bladder  into 
the  cellular  interval  between  the  scrotal  and  abdominal 
fasciae,  and  its  direction  is  limited  by  the  attachments  of 
the  fascia  already  named.  Commencing  at  first  in  the 
scrotum,  it  ascends  over  the  pubes  and  abdomen  and 
cellular  tissue  of  penis,  but  cannot  descend  down  the 
thighs,  owing  to  the  attachment  of  the  deep  layer  of 
superficial  fascia  along  Poupart's  ligament.  In  the  case 
of  wound  of  the  urethra  from  without,  such,  for  instance, 
as  a  blow  in  the  perineum,  not  only  is  the  urethra!  tube 
itself  ruptured,  but  the  fascia?  enveloping  it,  often  to  an 
unlimited  extent ;  hence  the  urine  may  follow  almost 
any  course,  and  not  restrict  itself  to  anatomical  relations. 

The  course  taken  by  urine  is  often  rather  theoretical 
than  real.  For  instance,  in  actual  practice  the  inflam- 
mation set  up  by  the  escape  of  urine,  whether  owing  to 
a  false  passage,  or  to  the  lesion  of  the  urethral  walls, 
causes  rapid  perforation  from  gangrene,  resulting  in  loss 
of  substance.  Moreover,  there  is  always  a  considerable 
number  of  natural  openings  and  passages,  undescribed 
by  the  anatomist,  but  readily  found  out-  by  an  infiltrat- 
ing fluid,  through  which  it  passes  and  frequently  shows 
itself  in  the  most  unexpected  places.  ( Vide  Perineum.) 


200  EXTERIOR    OF    PELVIS,    ETC. 

The  spermatie  cord  consists  of  external  spermatic  fascia, 
cremaster,  infundibuliform  fascia,  vessels,  lymphatics, 
nerves,  and  the  vas  deferens,  which  can  be  readily 
isolated  from  the  other  structures,  being  recognized  by 
its  whipcord-like  texture.  The  arteries  of  the  cord 
are  the  spermatic,  deferential,  and  the  cremasteric;  of 
these  the  spermatic  supplies  the  substance  of  the  testis, 
passing  into  it  either  through  the  tunica  albuginea,  or 
through  the  back  of  the  mediastinum  testis.  The  veins, 
passing  from  the  testis,  unite  in  forming  the  pampiniform 
plexus,  which  passes  into  a  single  trunk  forming  in  the 
body  of  the  cord,  and  terminating,  the  right  one  in  the 
vena  cava,  and  the  left  in  the  left  renal  vein. 

The  veins  of  the  cord  are  very  liable  to  a  varicose 
condition  (varicocele),  which  is  due  to  several  anatomical 
causes:  (1)  their  tortuous  arrangement  and  free  anas- 
tomoses at  their  emergence  from  the  gland ;  (2)  their 
want  of  support,  lying  as  they  do  in  the  loose  areolar 
tissue,  which  allows  of  the  weight  of  the  contained  col- 
umn of  blood  obliterating  their  valves ;  (3)  the  pressure 
they  receive  in  their  passage  through  the  inguinal  canal. 
It  is  a  matter  of  fact  that  the  left  spermatic  veins  are 
more  liable  to  this  condition  than  the  right,  the  causes 
assigned  being,  that  the  left  testicle  hangs  lower,  and 
that  its  upward  current  of  blood  meets  at  a  right  angle 
that  proceeding  from  the  kidney  in  the  left  renal  vein, 
and  that  they  are  liable  to  constant  pressure  from  the 
contents  of  the  sigmoid  flexure  of  the  colon. 

The  lymphatics  are  numerous  and  large,  and  terminate 
in  the  lumbar  glands,  which  become  rapidly  affected  in 
malignant  disease  of  the  testis. 

In  addition  to  the  coverings  mentioned,  the  testicle 
has  that  derived  from  the  peritoneum ;  the  tunica  vagi- 


THE    MALE    PERINEUM.  201 

nalis,  the  result  of  the  descent  of  that  organ  into  the 
scrotum.  That  portion  of  the  peritoneum  which  is  thus 
cut  off  from  the  bag,  remains  as  a  shut  sac,  investing  the 
outer  surface  of  the  testis  (tunica  vag.  testis),  and  is  re- 
flected on  to  the  scrotum  (tunica  vag.  reflexa).  Collec- 
tions of  fluid  (hydrocele,  hcematocele)  are  thus  related  to 
the  testis — namely,  that  they  are  above  and  in  front  of 
it,  unless  there  be  any  abnormality,  such  as  an  inversion 
of  the  testis.  In  removal  of  the  testis  (castration),  the 
retraction  of  the  cord  into  the  abdominal  cavity,  owing 
to  the  action  of  the  cremaster  muscle,  is  liable  to  give 
trouble,  unless  it  be  firmly  secured. 

The  structures  divided  in  the  operation  of  castration 
would  be  as  follows:  (1)  the  scrotal  tissues,  with  the 
vascular  and  nervous  supply — viz.,  the  superficial  peri- 
neal  vessels  and  nerves,  inferior  pudendal  nerve,  super- 
ficial external  pudic  vessels ;  (2)  the  structures  entering 
into  the  formation  of  the  cord. 


SURGICAL  ANATOMY  OF  THE  MALE  PERINEUM. 

This  region  is  to  be  studied  when  the  body  is  placed 
in  what  is  known  as  the  lithotomy  position — that  is, 
with  the  legs  flexed  on  the  thighs,  and  the  thighs  on  the 
pelvis,  in  order  that  the  parts  to  be  examined  be  on  the 
stretch. 

In  the  erect  position  the  superficial  aspect  of  the  re- 
gion becomes  a  mere  fold. 

There  is  considerable  difference  in  the  descriptions 
given  by  authors  as  to  what  the  limits  of  the  perineum 
really  are:  some  including  all  those  structures  which 
close  in  the  inferior  outlet  of  the  pelvis,  its  entire  floor 
in  fact ;  others  dividing  this  lozenge-shaped  space  into 


202  SURGICAL    ANATOMY    OF 

two  triangles,  by  a  line  passing  from  one  tuberosity  of 
the  ischium  to  the  other,  in  front  of  the  anus,  and  call- 
ing all  in  front  of  it  the  perineum,  and  all  behind  it,  the 
anal,  or  ischio-rectal  region.  It  is  proposed  to  adopt 
the  latter  method  in  this  description,  and  it  will  be  seen 
that,  although  it  may  appear  arbitrary  as  far  as  the  su- 
perficial layer  of  fascia  is  concerned,  as  the  dissection 
proceeds  deeper  towards  the  inner  aspect  of  the  pelvis, 
the  arrangement  is  a  natural  one,  as  adapting  itself  to 
the  special  contents  of  each  triangular  space.  The 
boundaries  of  the  anterior  portion,  which  is  convex  in 
the  middle,  owing  to  the  position  of  the  bulb  of  the 
urethra,  are — below,  a  line  passing  horizontally  in  front 
of  the  anus  from  one  tuberosity  of  the  ischium  to  the 
other ;  and  laterally,  the  pubic  rami,  meeting  at  the 
symphysis ;  thus  forming  a  triangular  interspace,  which 
is  itself  divided  by  the  median  raphe  into  two  equal 
parts,  the  left  being  the  one  in  which  the  lateral  opera- 
tion of  lithotomy  is  performed,  supposing  the  operator 
to  be  right-handed.  This  raphe  indicates  the  course 
taken  by  the  urethra,  and  is  a  most  valuable  landmark 
in  all  operations  about  the  perineum.  The  sides  of  this 
triangular  space  are  about  three  inches  and  a  half  long, 
and  about  three  inches  across  the  base,  and  a  line  drawn 
from  the  apex  of  the  triangle  to  its  base,  about  three 
inches. 

Superficial  Dissection  of  the  Perineum. — A  staif  having 
been  introduced  into  the  bladder,  and  the  hair  shaved 
off  the  nates,  an  incision  is  to  be  made  through  the  in- 
tegument in  the  middle  line,  a  second  at  right  angles  to 
it  in  front  of  the  anus,  and  a  third,  parallel  to  the  latter 
across  the  base  of  the  scrotum.  The  flaps  thus  formed 
are  to  be  reflected  outwards,  when  the  subcutaneous  eel- 


THE    MALE    PERINEUM.  203 

lular  tissue,  which  is  very  adherent  to  the  integument 
along  the  middle  line,  is  met  with.  The  superficial 
fascia  may  be  conveniently  divided  into  two  layers :  the 
upper  containing  a  good  deal  of  fat  (which  considerably 
augments  the  depth  of  the  perineum  in  some  cases) ;  is 
continuous  with  that  of  the  scrotum  and  thighs,  and 
in  it,  or  immediately  beneath  it,  lie  the  superficial  peri- 
neal  vessels  and  nerves,  whilst  the  deeper  layer  has  im- 
portant attachments  and  is  more  membranous  in  texture. 
Externally,  it  is  attached  to  the  rami  of  the  pubes  and 
ischium,  outside  the  crura  and  erectores  penis ;  behind, 
it  is  continuous  with  the  deep  perineal  fascia,  or  triangu- 
lar ligament  of  the  perineum,  after  turning  round  the 
transversalis  perinei  j  and  in  front  it  is  continuous  with 
the  dartos  and  fasciae  at  the  root  of  the  penis ;  a  septum 
derived  from  it  passes  inwards,  dividing  the  posterior 
part  of  the  space  beneath  this  layer  of  fascia  into  two, 
but  is,  however,  ill-defined  in  front.  This  cellulo-fatty 
layer  is  a  favorite  seat  of  abscess  from  urinary  or  other 
infiltration. 

The  attachments  of  this  fascia  are  very  important  as 
directing  the  course  of  the  urine  in  extravasation,  from 
rupture  of  the  urethra  anterior  to  the  triangular  ligament, 
into  the  cellular  tissue  of  the  scrotum  and  penis. 

Along  the  mesial  line  this  fascia  is  intimately  attached 
to  the  bulb  of  the  urethra,  and  in  cases  where  the  bulb 
has  been  injured,  the  urine,  after  extravasation,  readily 

»  finds  its  way  along  the  spongy  portion  of  the  urethra  to 
the  glans,  with  which  it  is  continuous.  On  reflecting 
this  layer  of  fascia,  in  the  middle  of  the  space,  are  the 
acceleratores  urinse  muscles,  enveloping  the  bulb,  and  on 
either  side  are  the  erectores  penis,  passing  from  the  inner 
aspect  of  the  ascending  ramus,  and  covering  the  lower 


204:  SURGICAL    ANATOMY    OF 

portions  of  the  crura.  Lying  somewhat  obliquely  to  the 
central  tendon  are' the  transverse  muscles  of  the  perineum. 
This  central  tendon  is  a  white  fibrous  knot,  and  acts  as 
a  point  d'appui  for  the  accelerators  urinse  and  external 
sphincter  muscles ;  it  is  situated  in  the  median  line  be- 
tween the  urethra  and  the  anus.  Lying  between  and 
upon  the  erectores  penis  and  the  acceleratores  urinae,  are 
the  trunks  of  the  superficial  perineal  vessels  and  nerve, 
and  some  inosculating  branches  of  the  inferior  pudendal, 
and  on  or  below  the  posterior  border  of  the  transversus 
perinei  muscle  lie  the  transverse  perineal  vessels  and  nerve. 
The  acceleratores  urina?  are  separated  from  the  deep 
layer  of  superficial  fascia  by  a  thin  aponeurotic  layer. 
This  muscle,  which  compresses  the  bulb,  and  empties 
the  bulbous  urethra,  is  generally  described  as  consisting 
of  three  portions,  commencing  from  the  median  raphe, — 
an  anterior,  which  passes  round  the  penis  to  be  inserted 
on  its  upper  aspect,  sending  an  expansion  which  com- 
presses the  dorsal  vein ;  a  middle,  which  incloses  the  in- 
ferior portion  of  the  urethra,  and  passes  between  it  and 
the  body  of  the  penis;  and  a  posterior,  which  is  attached 
to  the  anterior  surface  of  the  triangular  ligament. 

It  will  be  observed  that  the  perineal  muscles  of  one 
side  form  a  triangular  space,  having  the  triangular  liga- 
ment as  its  floor,  while  from  its  outer  angle  emerge  the 
superficial  perineal  vessels,  and  the  transverse  perinei 
vessels  and  nerves  coming  to  the  surface ;  the  relations 
of  the  space  are  of  importance,  as  in  the  lateral  operation 
of  lithotomy  the  first  incision  traverses  it. 

If  the  accelerator  urinse  muscle  be  now  carefully  de- 
tached by  making  an  incision  along  the  raphe,  the  bulb 
of  the  urethra  is  exposed,  small  in  childhood,  and  large 


THE    MALE    PERINEUM.  205 

in  advanced  age,  and  closely  bordering  on  the  margin  of 
the  anus ;  this  fact  is  of  importance,  as  there  is  greater 
danger  of  wounding  the  bulb  in  the  lateral  operation  of 
lithotomy  in  old  persons.  The  cms  penis  and  its  muscle 
should  now  be  drawn  outwards  (or  entirely  removed), 
and  the  rectum  drawn  downwards,  when  the  anterior 
surface  of  the  triangular  ligament  will  be  seen  as  a  tough 
bluish-white  structure — the  fibres  of  which  are  nearly  all 
transverse — allowing  of  the  structures  between  the  two 
layers  being  readily  seen  through  it  in  favorable  subjects; 
its  base  is  directed  towards  the  rectum,  it  is  attached  in 
the  middle  line  to  the  central  tendon  of  the  perineum, 
and  laterally  to  the  rami  of  the  ischium  and  pubes,  hav- 
ing a  free  margin  on  either  side  of  the  central  tendon, 
which  is  continuous  with  the  deep  layer  of  superficial 
fascia ;  its  apex  is  directed  upwards,  and  is  connected 
with  the  periosteum  in  front  of  the  symphysis  pubis.  Tt  is 
perforated  at  about  an  inch  below  the  symphysis  by  the 
urethra,  with  which  it  is  intimately  connected,  and  which 
here  changes  its  direction,  and  between  the  urethra  and 
the  symphysis  lie  the  vessels  of  the  penis,  the  dorsal 
vein  or  veins  in  the  centre,  on  either  side  of  it  the  dorsal 
arteries,  and  most  externally  are  the  dorsal  nerves. 

The  bulb  may  now  be  separated  from  the  triangular 
ligament  (if  both  sides  of  the  perineum  be  available), 
turned  upwards,  and  the  triangular  ligament  itself  care- 
fully detached  from  the  bone.  A  considerable  plexus 
of  veins  is  usually  first  met  with,  and  care  must  be  taken 
not  to  divide  it,  as  the  blood  would  obscure  the  view  of 
the  parts  between  the  layers  of  the  triangular  ligament, 
which  consist  of  the  following  structures, — a  plane  of 
muscular  fibres,  variously  described  by  different  authors, 
as  the  levator  and  compressor  urethras,  surrounding  the 

18 


206  SURGICAL    ANATOMY    OF 

membranous  portion  of  the  urethra,  which  lies  between 
these  layers  of  fascia,  and  receives  a  prolongation  from 
each ;  the  deep  transversus  perinei ;  the  internal  pudic 
artery  and  nerve,  the  former  giving  off  the  artery  to  the 
bulb  and  to  Cowper's  gland;  the  artery  to  the  corpus 
cavernosum,  and  the  dorsal  artery  of  the  penis;  and  just 
below  the  urethra,  Cowper's  glands,  their  ducts,  and  the 
subpubic  ligament.  Beneath  this  layer  of  muscular 
fibres  and  vessels  is  the  posterior  layer  of  the  triangular 
ligament,  derived  from  the  pelvic  fascia. 

Note. — Before  proceeding  with  the  deep  dissection  of 
the  perineum  it  will  be  found  expedient  to  study  the 
anal  region. 

Dissection  of  the  Anal  or  Ischio-rectal  Region. — An 
incision  is  to  be  made  commencing  just  in  front  of  the 
anus,  round  which  it  is  to  be  carried  to  the  tip  of  the 
coccyx,  another  at  right  angles  to  it,  immediately  behind 
the  termination  of  the  rectum,  and  the  flaps  reflected 
outwards.  As  the  external  sphincter  is  incorporated 
with  the  integument,  great  care  must  be  taken  not  to 
remove  it,  on  dissecting  off  the  flap ;  this  is  next  to  im- 
possible, however,  if  the  dissection  be  conducted  in  the 
usual  manner,  as  the  skin  of  the  whole  of  the  perineum 
posteriorly  is  interwoven  with  muscular  fibres. 

In  the  middle  line  of  this  space  lies  the  anus,  the  mu- 
cous membrane  of  which  is  not  seen,  in  the  normal  state, 
during  life.  If,  however,  the  anus  be  gently  opened  at 
the  junction  of  the  mucous  membrane  with  the  skin,  a 
pale  line  is  to  be  seen,  marking  the  position  of  the  in- 
ternal sphincter,  a  thickening  of  the  muscular  fibres  of 
the  lower  portion  of  the  rectum.  This  band  of  muscu- 
lar fibres  plays  an  important  part  in  preventing  the  heal- 
ing of  ulcers  and  fissures  of  the  rectum,  by  keeping  the 


THE    MALE    PERINEUM.  207 

tissues  on  the  stretch.  These  ulcers  are  generally  situ- 
ated about  a  quarter  of  an  inch  or  so  from  the  verge, 
just  within  the  sphincter,  and  generally  either  in  front 
of,  or  at  the  side  of  the  coccyx.  The  treatment  consists 
in  dividing  the  fibres  with  a  view  to  relieve  the  tension. 
In  operating  on  the  female,  care  must  be  taken  in  mak- 
ing the  incision,  if  on  the  anterior  wall  of  the  bowel,  on 
account  of  the  proximity  of  the  vagina.  If  the  verge 
of  the  anus  be  carefully  examined  it  will  be  seen  to  con- 
tain a  large  number  of  follicles,  suppuration  in  which  is 
often  mistaken  for  fistula — a  disease  which  is  frequently 
difficult  to  diagnose  correctly  without  a  good  view  of  the 
interior  of  the  gut,  of  which  an  inch  or  an  inch  and  a 
half  must  be  exposed  for  the  purpose ;  and  it  is  a  fact 
of  great  surgical  importance  that  the  internal  opening  of 
a  fistula  is  always  within  this  distance  of  the  orifice. 

The  external  opening  of  the  rectum  is  occasionally 
wanting  (atresia  ani). 

The  lower,  or  perinea!  portion  of  the  rectum,  is  not 
much  more  than  an  inch  in  length;  it  curves  back  below 
the  prostate,  and  is  uncovered  by  peritoneum.  Just 
above  the  anus  the  rectum  is  considerably  dilated,  a  con- 
dition increased  by  age  and  constipation.  The  folds  of 
mucous  membrane,  in  the  empty  state  of  the  rectum,  so 
overlap,  that  considerable  difficulty  may  be  experienced 
in  passing  the  finger  or  a  bougie  through  them ;  one 
fold  in  particular  often  obstructs  the  finger,  at  about  an 
inch  and  a  half  above  the  aperture.  The  mucous  mem- 
brane of  the  lower  end  of  the  bowel  is  very  loose,  and 
readily  admits  of  the  burrowing  of  matter.  It  must  be 
borne  in  mind  that  the  curve  of  the  bowel  above  men- 
tioned necessitates  caution  in  the  introduction  of  an 
enema-tube  or  other  instrument,  which  should  be  di- 


208  SURGICAL    ANATOMY    OF 

reeled  obliquely  from  below  upwards  and  forwards,  and 
afterwards,  upwards  and  backwards. 

A  dilated  condition  of  the  inferior  haBmorrhoidal 
veins  at  the  lower  part  of  the  anus  constitutes  external 
piles. 

The  superficial  fascia,  tough  and  strong,  and  contain- 
ing a  great  deal  of  fat,  has  cutaneous  vessels  and  nerves 
passing  through  it.  The  external  sphincter  muscle  is 
seen  attached  posteriorly  to  the  tip  of  the  coccyx,  and 
inclosing  the  margin  of  the  anus,  is  inserted  into  the 
central  tendon  before  mentioned.  This  circular  band  of 
fibres  is  about  one  inch  in  breadth.  Between  the  bowel 
and  the  tuberosities  of  the  ischium  is  the  ischio-rectal 
fossa,  which  contains  a  quantity  of  loose  fat  and  cellular 
tissue,  and  lying  across  it,  and  passing  to  the  margin  of 
the  anus,  are  the  superficial  hsemorrhoidal  vessels  and 
nerves,  which  are  liable  to  give  a  good  deal  of  trouble 
from  hemorrhage,  when  cut  in  operations  for  fistula,  &c. 
On  cleaning  out  the  space  its  shape  and  boundaries  can 
be  defined.  In  shape  it  is  somewhat  triangular,  about 
an  inch  in  width,  and  about  two  inches  deep ;  inferiorly 
its  base  is  formed  by  the  integuments  of  the  region,  and 
its  apex,  directed  upwards,  corresponds  to  the  interval 
between  the  lower  border  of  the  obturator  internus, 
covered  by  the  obturator  fascia,  and  the  outer  surface  of 
the  levator  ani,  covered  by  the  anal  fascia.  Its  bounda- 
ries are, — externally,  the  tuberosity  of  the  ischium  and 
obturator  fascia;  internally,  the  sphincter  ani,  levator 
ani,  covered  by  anal  fascia,  and  coccygeus ;  anteriorly, 
the  triangular  ligament ;  and  posteriorly,  the  gluteus 
maximus  and  great  sacro-sciatic  ligament. 

Lying  in  a  fold  derived  from  the  obturator  fascia,  on 
the  outer  wall  of  the  fossa,  the  trunks  of  the  internal 


THE    MALE    PERINEUM.  209 

pudic  vessels  and  nerve  can  be  easily  felt,  grooving  the 
inner  aspect  of  the  tuber  osity  of  the  ischium. 

In  the  external  incision  for  lateral  lithotomy  the  knife 
sinks  into  the  ischio-rectal  fossa,  and  will  divide  the 
superficial  hsemorrhoidal  vessels  and  nerves.  Abscesses 
have  a  great  partiality  for  the  ischio-rectal  fossae,  and 
often  burrow  to  a  most  remarkable  extent.  A  fistula  in 
ana,  is  the  sinus  left  on  the  contraction  of  the  cavity  of 
such  an  abscess.  True  fistulse  exist  external  to  the 
sphincter,  and  always  extend  as  far  up  as  its  upper 
border.  They  are  called  complete  or  incomplete  accord- 
ing as  their  openings  are  situated ;  thus,  in  the  former 
case,  one  opening  is  in  the  rectum  and  the  other  on  the 
surface  of  the  body,  generally  near  the  anus;  in  the 
latter,  there  is  an  opening  into  the  bowel  and  none  ex- 
ternal, or  the  converse. 

The  operation  for  its  cure  consists  in  passing  a  knife 
through  the  fistulous  track  into  the  bowel,  and  cutting 
through  all  the  tissues  between  the  edge  of  the  knife  and 
the  interior  of  the  gut.  These  tissues  are — the  pseudo- 
mucous  membrane  of  the  fistula,  the  external  sphincter, 
some  few  fibres  of  the  levator  ani,  the  branches  of  the 
inferior  hsemorrhoidal  vessels  and  nerves,  the  internal 
sphincter,  and  the  mucous  membrane  of  the  inner  bowel 
and  its  vessels. 

Deep  Dissection  of  the  Perineum. — Those  structures  be- 
fore described  as  lying  beneath  the  anterior  layer  of  the 
triangular  ligament  may  be  now  removed,  when  its  pos- 
terior layer  will  come  into  view.  This  is  derived  from 
the  pelvic  fascia,  and  covers  the  hinder  part  of  the  mem- 
branous urethra,  and  outer  surface  of  the  prostate  gland ; 
it  is  attached  below  to  the  anterior  layer,  forming  a 


210  SURGICAL    ANATOMY    OF 

pouch  on  either  side  of  and  below  the  urethra,  in  which 
lie  Cowper's  glands. 

On  detaching  this  posterior  layer,  the  anterior  fibres 
of  the  levator  ani  are  seen,  passing  by  the  sides  of  the 
prostate,  and  uniting  on  its  perineal  surface  with  the 
muscle  of  the  opposite  side,  and  blending  at  the  central 
tendon  with  the  fibres  of  the  external  sphincter  and 
transverse  perineal  muscles.  The  central  fibres  are  in- 
serted into  the  side  of  the  rectum,  interlacing  with  the 
sphincters,  and  the  posterior  are  attached  to  the  coccyx 
and  median  raphe  behind  the  rectum.  These  muscles 
and  the  triangular  ligament  shut  in  the  inferior  outlet 
of  the  pelvis. 

In  order  to  obtain  a  view  of  the  relations  of  the 
structures  which  lie  at  the  inferior  outlet  of  the  pelvis, 
as  they  would  be  met  with  in  a  surgical  operation,  the 
rectum  should  be  detached  from  its  connections  by  di- 
viding the  anterior  and  lateral  portions  of  the  levator 
ani,  and  pulled  backwards,  when  the  under  surface  of 
the  prostate,  the  neck  and  base  of  the  bladder,  vesicular 
seminales,  and  vasa  deferentia  will  be  seen  (Fig.  36). 

The  general  form  of  the  normal  prostate  is  that  of  a 
chestnut,  with  its  base  directed  towards  the  bladder,  and 
its  apex  towards  the  symphysis,  having  its  longest  diam- 
eters antero-posteriorly,  and  at  its  base  transversely. 
Its  inferior  surface  rests  flat  on  the  triangular  ligament 
and  membranous  portion  of  the  urethra ;  its  upper  sur- 
face, slightly  concave,  is  intimately  connected  with  the 
bladder  and  ejaculatory  ducts,  which  lie  together  in  the 
middle  line  immediately  behind  it.  Its  anterior  surface 
corresponds  to  the  deep  layer  of  the  triangular  ligament 
(pubo-prostatic  ligament);  the  posterior  surface  is  sepa- 
rated from  the  rectum  simply  by  a  little  cellular  tissue 


THE    MALE    PERINEUM.  211 

and  is  applied  to  the  neck  of  the  bladder ;  and  its  sides 
are  in  relation  with  the  levator  ani  and  with  the  pelvic 
fascia.  The  prostate  is  invested  by  a  fibrous  capsule, 
derived  from  the  pelvic  fascia.  The  density  of  this  cap- 
sule accounts  for  the  intense  pain  of  prostatic  abscesses, 
and  forces  the  pus  to  find  its  way,  unless  relieved,  into 
the  urethra.  In  opening  these  abscesses  in  the  perineum, 
there  is  a  possibility  of  urinary  fistula,  and  in  the  event 
of  their  bursting  in  the  perineum,  such  fistulse  are  cer- 
tain to  form. 

The  position  of  the  prostate  gland  is  readily  determined 
by  passing  the  finger  into  the  rectum,  and  if  healthy  is 
generally  felt  about  as  far  up  as  the  second  joint  of  the 
forefinger  reaches,  whilst  in  some  forms  of  enlargement, 
the  upper  border  of  the  gland  will  be  far  out  of  reach  of 
the  entire  finger. 

The  relations  of  the  bladder  and  the  rectum,  within  the 
reach  of  the  finger,  are  of  great  importance;  thus,  in 
cases  of  retention  of  the  urine,  when  it  is  necessary  to 
perform  the  operation  of  puncture  per  rectum,  the  dis- 
tended bladder  is  felt  overlapping  the  posterior  margin 
of  the  prostate  at  a  point  where,  if  the  puncture  be  made 
in  the  mesial  line,  no  injury  to  surrounding  parts  could 
take  place,  as  the  instrument  would  pass  between  the 
vesiculse  seminales,  and  perforate  a  space  (trigone  vesicce) 
where  these  structures  are  neither  covered  by  pelvic 
fascia  nor  by  peritoneum.  The  digital  examination  of 
the  bladder  per  rectum  assists  the  surgeon  in  the  detec- 
tion or  dislodgment  of  vesical  calculi,  in  guiding  the 
point  of  a  catheter  or  sound  in  cases  of  difficulty,  and  in 
the  detection  of  prostatic  abscesses,  or  growths. 

Parts  concerned  in  Lateral  Lithotomy  in  the  Adult. — 
The  object  to  be  attained,  is  that  of  opening  the  bladder 


212  SURGICAL    ANATOMY    OF 

at  one  particular  spot,  its  neck,  and  for  the  reason  that 
if  opened  at  any  other,  urinary  infiltration  into  the  areo- 
lar  tissue  of  the  pelvis  will  take  place.  The  incisions 
then  must  be  made  in  the  most  direct  way,  to  allow  of 
(1),  the  position  of  the  staff,  which  has  been  introduced 
into  the  bladder,  being  felt ;  (2),  the  neck  of  the  bladder 
being  opened,  and  room  obtained  for  the  extraction  of 
the  stone. 

The  perineum  having  been  shaved,  the  skin  and  in- 
teguments are  to  be  steadied  and  rendered  tense  with  the 
fingers  of  the  left  hand,  and  the  point  of  the  knife  is  to 
be  entered  about  an  inch  and  three-quarters  in  front  of 
the  anus,  a  little  to  the  left  of  the  middle  line,  and  car- 
ried through  the  skin,  in  a  direction  downwards  and 
outwards,  midway  between  the  anus  and  the  tuberosity 
of  the  ischium.  The  left  forefinger  is  next  to  be  pushed 
into  this  external  wound,  with  the  double  purpose  of 
feeling  for  the  position  of  the  groove  of  the  staif  in  the 
urethra,  and  for  the  purpose  of  pushing  the  rectum  in- 
wards and  backwards  out  of  the  way.  When  the  groove 
is  recognized,  the  knife,  lying  flat  under  the  introduced 
finger,  is  pushed  into  the  urethra  just  in  front  of  the 
prostate,  and  when  the  point  is  felt  to  be  in  the  groove, 
it  is  made  to  slide  along  it  towards  the  bladder,  dividing 
in  its  course,  the  membranous  urethra  and  left  lobe  of 
the  prostate  to  the  extent  of  an  inch.  The  forefinger  is 
now  to  be  pushed  along  the  groove,  through  the  edges 
of  the  deep  wound,  and  insinuated  into  the  incision 
through  the  prostate  ;  the  staff  is  then  withdrawn  by  the 
assistant  in  charge  of  it,  whilst  the  finger  passes  into  the 
cavity  of  the  bladder.  The  forceps  are  next  guided  by 
the  under  surface  of  the  finger  into  the  bladder.  When 
the  stone  is  felt,  the  blades  must  be  opened,  the  finger 


THE    MALE    PERINEUM.  213 

gradually  withdrawn,  and  an  attempt  made  to  catch  it 
in  its  long  axis  if  possible.  When  caught,  it  is  to  be 
slowly  and  firmly  drawn  out,  without  hurry,  with  a 
slight  to  and  fro  motion  in  a  direction  downwards, 

FIG.  36. 


S  ction  of  pelvis  to  the  left  of  the  median  line  at  the  pubes,  and  through  the 
middle  line  at  the  sacrum.  1.  Section  of  left  pubic  bone.  2.  Peritoneum  on 
bladder.  3.  Left  crus  penis  (cut).  4.  Pelvic  fascia,  formirlg  anterior  ligaments 
of  bladder.  5.  Part  of  accelerator  urinse.  6.  Posterior  layer  of  triangular  liga- 
ment, or  pelvic  fascia  forming  the  capsule  of  the  prostate.  7.  Anterior  layer  of 
triangular  ligament,  or  deep  perineal  fascia.  Between  6  and  7  are  seen  the  fol- 
lowing: Membranous  urethra,  deep  muscles  of  urethra  (insertion),  and  Cowper's 
gland  of  the  left  side.  8.  Vas  deferens.  9.  Bulb  of  urethra.  10.  Rectum.  11. 
Cut  edges  of  accelerator  urinae  and  transversus  perinei.  12.  Left  ureter.  13.  Re- 
flection of  deep  layer  of  superficial  fascia  round  transversus  perinei.  14.  Left 
vesicula  seminalis.  15.  Cut  edge  of  levator  ani.  16.  Rectum.  17.  Prostate. 
(HEATH.) 

towards  the  floor,  and  not  horizontally  towards  the 
pubic  arch.  After  the  operation,  a  searcher  or  sound  is 
to  be  introduced  to  find  out  whether  the  bladder  is  free. 
Structures  Divided  in  the  Lateral  Operation  of  Lith- 
otomy.— The  superficial  incision  divides  the  skin  and 


214  SURGICAL    ANATOMY    OP 

superficial  fascia,  inferior  hsemorrhoidal  vessels  and 
nerves,  which  lie  superficially  in  the  anterior  part  of  the 
ischio-rectal  fossa,  transversus  perinei  muscles  and  ves- 
sels, and  superficial  perineal  vessels  and  nerves.  The 
structures  divided  on  the  staff  are  the  lower  part  of  the 
triangular  ligament,  deep  transversus  urethrse  muscle ; 
the  deep  part  of  the  incision  divides  the  membranous 
urethra,  the  substance  of  the  prostate,  and  vessels 
around  it. 

Structures  to  be  Avoided. — The  bulb,  or  the  rectum, 
which  stands  a  risk  of  being  wounded,  if  the  first  inci- 
sion be  too  near  the  middle  line;  the  internal  ptidic 
artery,  if  on  the  other  hand  the  deep  incision  be  made 
too  far  externally ;  the  artery  to  the  bulb,  if  it  be  made 
too  far  forward;  and  the  entire  breadth  of prostate,  with 
its  capsule,  and  the  ejaculatory  ducts,  if  it  be  carried  too 
far  backwards  or  downwards. 

If  the  entire  breadth  of  the  gland  and  its  capsule  were 
divided,  the  urine  would  be  infiltrated  beneath  the  peri- 
toneum. 

The  depth  of  the  perineum  between  the  neck  of  the 
bladder  and  the  integument  varies  from  rather  more 
than  an  inch  to  four  inches,  and  between  the  tuberosities 
of  the  ischium  from  two  inches  or  less,  to  four. 

In  the  child,  the  pelvis  being  narrow,  the  perineum  is 
narrow  also ;  and  the  neck  of  the  bladder  comparatively 
high  up,  whilst  the  peritoneum  descends  very  low  be- 
tween the  bladder  and  the  rectum.  The  bladder  itself  is 
more  conical  in  shape,  and  is  rather  an  abdominal  than 
a  pelvic  viscus,  and  its  connection^  with  the  surrounding 
parts  are  very  loose.  Hence  the  difficulty  experienced 
in  getting  into  the  bladder  in  lateral  lithotomy  in  chil- 
dren, and  the  danger  of  pushing  the  prostate  before  the 


THE    MALE    PERINEUM. 


215 


finger  and  tearing  it  from  the  membranous  portion  of 
the  urethra.  There  is  also  danger  of  cutting  the  urethra 
considerably  anterior  to  the  point  indicated  as  the  exact 


FIG.  37. 


w 


(The  bulb  is  slightly  raised  and  the  rectum  drawn  backwards,  in  order  to  make 
clear  the  membranous  urethra  and  prostate,  which  are  shown  incised  as  in  the 
lateral  operation  of  lithotomy.)  1.  Bulb.  2.  Rectum.  3.  Gluteus  maximus.  4. 
External  sphincter.  5.  Levator  ani,  its  anterior  fibres  raised  to  show  the  pros- 
tate. 6.  Erector  penis.  7.  Wilson's  muscle.  8.  Cowper's  gland.  9.  Trunk  of 
internal  pudic.  10.  Superficial  perineal  artery.  11.  Artery  to  bulb  (abnormal). 
12.  Artery  to  bulb.  13.  Continuation  of  internal  pudic  artery.  14.  Membranous 
urethra  divided  as  in  the  lateral  incision.  15.  Prostate  gland,  with  its  plexus  of 
vessels.  16.  Incision  in  the  prostate  gland  as  in  the  latvral  operation.  17.  An- 
terior layer  of  triangular  ligament.  18.  Transversus  perinei  muscle.  (RICHET.) 


216  SURGICAL    ANATOMY    OF 

position  for  entering  the  bladder,  therefore  always,  in 
children,  the  external  incision  should  be  made  as  large 
as  possible,  that  the  relative  position  of  the  parts  be 
clearly  made  out. 


SUKGICAL  ANATOMY  OF  THE  PENIS  AND 
MALE  UKETHHA. 

The  integument  of  the  penis  consists  externally,  of 
very  lax,  loose  skin,  destitute  of  fat,  which  at  the  corona 
glandis  is  reflected  over  the  glans,  and  has  an  internal 
mucous  surface  continuous  with  that  of  the  glans ;  imme- 
diately below  the  meatus  urinarius  this  membrane  is 
gathered  into  a  fold,  the  frcenum  preputii.  Behind  the 
corona,  and  in  the  sulcus,  are  a  number  of  glands  which 
secrete  the  smegma.  Beneath  the  skin  is  a  layer  of  loose 
muscular  fibres,  analogous  to  the  dartos,  arranged  circu- 
larly and  lying  in  loose  cellular  tissue.  Beneath  this  is 
a  tough,  elastic  fascia,  enveloping  the  entire  body  of  the 
organ,  sending  in  a  process  beneath  the  urethra  and 
corpora  cavernosa,  continuous  with  the  superficial  fascia 
of  the  perineum,  incorporated  at  its  root  with  the  suspen- 
sory ligament;  between  the  two  laminae  of  which  lie  the 
dorsal  vessels  and  nerves.  The  upper  portion  of  the 
body  of  the  penis  is  composed  of  the  corpora  cavernosa, 
which,  arising  from  the  inner  aspect  of  the  horizontal 
rami  of  the  pubes,  unite  along  the  mesial  line,  this  union 
being  marked  by  a  septum,  called  the  septum  peetini- 
forme,  which,  however,  is  wanting  in  front.  The  cor- 
pora cavernosa  terminate  in  the  front,  by  a  rounded  mar- 
gin, which  projects  into  the  base  of  the  glans.  The 
inferior  portion  of  the  body  of  the  glans  is  formed  by  the 
corpus  spongiosum,  containing  the  urethra.  It  com- 


THE    MALE    URETHRA.  217 

mences  in  front  of  the  triangular  ligament  at  the  bulb, 
and  lying  between  and  below  the  united  crura,  termi- 
nates at  the  glans. 

The  arteries  of  the  penis  are  the  dorsal,  which  lie  in 
the  dorsal  furrow,  supplying  the  integument,  and  after- 
wards pierce  its  fibrous  investment,  near  the  corona ;  the 
arteries  to  the  corpora  cavernosa,  and  the  arteri.es  to  the 
bulb.  The  veins  are  very  numerous,  and  are  superficial 
and  deep,  the  former  passing  into  the  dorsal  vein,  which 
lies  between  the  two  dorsal  arteries,  and  generally  termi- 
nates in  the  internal  saphena;  and  the  deep,  after  pierc- 
ing the  triangular  ligament,  terminate  in  the  prostatic 
plexus. 

The  lymphatics,  with  which  the  organ  is  richly  fur- 
nished, accompany  the  dorsal  vessels  and  pass  into  the 
ganglia  of  the  fold  of  the  groin. 

The  nerves  lie  external  to  the  arteries  on  the  dorsum, 
and  are  freely  distributed  to  the  body  and  glans. 

The  penis  is  often  the  seat  of  an  arrest  of  develop- 
ment, one  form  of  which,  where  the  anterior  wall  of  the 
urethra  is  wanting,  is  termed  epispadias  ;  and  where  the 
superior  wall  is  wanting,  and  generally  associated  with 
extroversion  of  the  bladder,  hypospadias.  Occasionally 
the  prepuce  completely  incloses  the  glans,  excepting  a 
minute  orifice  through  which  the  urine  passes  (congenital 
phimosis). 

SUKGICAL  ANATOMY  OF  THE  MALE  URETHRA. 

Supposing  in  the  first  instance  the  parts  removed  from 
the  body,  for  the  sake  of  examining  the  canal,  the  urethra 
may  be  described  as  extending  from  the  neck  of  the 
bladder  to  the  meatus  urinarius,  and  is  from  eight  to 
nine  inches  in  length,  and  for  general  division  consists 


218  SURGICAL    ANATOMY    OF 

of  one  portion  belonging  to  the  penis,  and  of  another  be- 
longing to  the  perineum ;  with  the  former  is  included 
the  spongy  portions,  and  with  the  latter  the  membran- 
ous and  prostatie. 

Spongy  Portion. — Commencing  from  the  orifice  of  the 
urethra,  a  vertical  slit  provided  with  two  lip-like  mar- 
gins, the  urethral  tube  is  seen  at  its  most  constricted 
portion.  On  examining  the  floor  of  the  canal  within  the 

FIG.  38. 


Longitudinal  section  of  the  bladder,  prostate  gland,  and  penis.  1.  Urachus.  2. 
Recto-vesical  fold  of  peritoneum.  3.  Opening  of  the  right  ureter.  4.  A  slight 
ridge  formed  by  the  muscle  of  the  ureter.  5.  The  neck  of  the  bladder.  6.  Pros- 
tatie portion  of  the  urethra.  7.  Prostate  gland.^  8.  The  common  ejaculatory 
duct.  9.  Right  vesicula  seminalis;  the  vas  deferens  is  cut  short.  10.  Membran- 
ous portion  of  the  urethra.  Its  direction  is  the  reverse  of  this  when  in  situ.  11. 
Cowper's  gland  of  the  right  side,  with  its  duct.  12.  Bulbous  portion  of  the 
urethra.  13.  Fossa  navicularis.  14.  Corpus  cavernosum.  15.  Right  crus  penis. 
16.  A  portion  of  the  septum  pectiniforme.  17.  The  glans  penis.  18.  Corona 
glandis.  19.  Meatus  urinarius.  20.  Corpus  spongiosum.  21.  Bulb  of  the  corpus 
epongiosum.  (WILSON.) 

meatus,  a  considerable  dilatation  is  found,  termed  the 
fossa  navicularis,  and  on  the  roof  of  this  part  of  the 
urethra  is  the  orifice  of  a  large  mucous  pouch,  the  lacuna 
magna.  Behind  this  dilatation  the  canal  averages  about 


THE    MALE    URETHRA.  219 

a  quarter  of  an  inch  in  diameter,  and  is  throughout  stud- 
ded, particularly  on  its  floor,  with  the  orifices  of  glands 
(glands  of  Littre),  opening  forwards.  About  five  inches 
behind  the  orifice  is  another  pouch-like  dilatation  con- 
tained within  the  bulb,  into  the  floor  of  which  open  the 
ducts  of  Cowper's  glands. 

Membranous  Portion. — This  is  the  narrowest  portion 
of  the  tube  throughout  its  length,  excepting  the  sphincter- 
like  orifice,  and  is  contained  between  the  layers  of  the 
triangular  ligament ;  it  measures  about  three-fourths  of 
an  inch  along  its  upper,  and  half  an  inch  along  its  lower 
surface,  and  consists  of  mucous  membrane,  elastic,  erec- 
tile, and  muscular  tissue. 

The  prostatic  portion  is  the  widest  and  most  dilatable 
portion  of  the  urethra ;  it  is  about  an  inch  and  a  quarter 
long,  and  lies  nearer  the  upper  than  the  lower  portions 
of  the  gland,  and  its  tube  is  of  greater  calibre  in  the 
middle  than  at  either  entrance  or  exit ;  on  its  floor,  at 
the  neck  of  the  bladder,  is  the  uvula  vesica?,  in  front  of 
which  is  a  ridge  of  mucous  membrane,  rather  deeper 
behind  than  before,  called  the  veru  montanum  or  caput 
gattinaginis,  having  on  either  side  of  it  a  pouch  or  sinus, 
into  which  open  the  prostatic  ducts.  At  the  fore  part  of 
the  veru  montanum  is  a  cul-de-sac,  running  upwards 
and  backwards  beneath  the  middle  lobe,  containing  on 
its  floor  the  openings  of  the  ejaculatory  ducts ;  it  is  called 
the  sinus  pocularis. 

Next,  let  the  urethra  be  examined  as  existing  during 
life,  as  it  would  present  itself  to  the  surgeon. 

The  urethra  may  be  thus  divided  into  a  penile  and  a 
periueal  portion,  and  the  individual  lying  on  his  back, 
the  usual  position  for  catheterism,  its  direction  can  be 
conveniently  described  as  an  ascending  portion,  ter- 


220  SURGICAL    ANATOMY    OP 

minating  at  the  root  of  the  penis  and  descending  at  the 
bulb;  and  a  descending,  comprising  the  membranous  and 
prostatic.  Thus  the  points  where  the  urethra  changes  di- 
rection are  at  the  root  of  the  penis  and  bulb,  and  it  is  in 
this  portion  of  the  canal  that  false  passages  are  most  fre- 
quently made.  These  curves  disappear  on  catheterism  ; 
the  first  by  merely  raising  the  penis,  and  the  second  on  the 
depression  of  the  handle  of  the  instrument  between  the 
thighs.  So  resilient  are  the  urethral  walls  that  a  perfectly 
straight  instrument  can  be  readily  introduced  into  the 
bladder.  The  urethral  canal  is  distant  from  the  under 
border  of  the  symphysis  about  half  an  inch  or  a  little 
more,  and  is  consequently  about  half  an  inch  or  a  little 
more  below  the  vesical  aperture,  which  corresponds  with 
the  lower  border  of  the  symphysis,  and  is  about  an  inch 
and  a  quarter  behind  it.  When  not  in  use  the  walls  of 
the  urethra  touch  each  other,  excepting  at  the  orifice  of 
the  meatus  urinarius  and  in  the  bulb,  where  they  are 
separated  by  a  narrow  interspace. 

Catheterism  of  the  Male  Urethra. — If  the  urethra  be 
healthy,  the  sound  or  catheter  will  pass  by  its  own 
weight,  and  require  scarcely  any  urging.  The  instrument 
is  to  be  introduced  into  the  orifice  of  the  urethra,  and 
pressed  gently  onwards  until  it  has  traversed  the  canal 
for  four  or  five  inches,  when  the  handle  is  to  be  brought 
to  the  middle  line  close  to  the  abdomen,  in  order  that 
the  point  may  traverse  the  curve  below  the  symphysis ; 
the  handle  is  then  to  be  brought  gently  down  towards 
the  surgeon,  when  it  should  glide  into  the  bladder. 
The  great  point  is  to  keep  the  extremity  of  the  instru- 
ment traversing  the  upper  wall  of  the  urethra.  Besides, 
being  less  movable,  experience  shows  that  in  cases  of 
stricture,  the  upper  wall  is  less  liable  to  be  affected  than 


THE    FEMALE    URETHRA.  221 

the  base  and  sides.  In  introducing  a  small  instrument, 
the  position  of  the  lacunae  must  be  borne  in  mind,  par- 
ticularly that  of  the  lacuna  magna,  on  the  upper  wall  of 
the  navicular  fossa,  as  it  is  liable  to  intercept  its  point; 
and  if  force  be  employed,  it  might  pass  beneath  the  mu- 
cous coat.  In  cases  of  difficulty,  by  passing  the  finger 
into  the  rectum  the  point  of  the  instrument  can  be  di- 
rected into  the  bladder,  on  account  of  the  close  relation 
of  the  membranous  portion  of  the  urethra  and  the  rec- 
tum, and  the  readiness  with  which  the  catheter,  or  sound, 
can  be  felt  through  it. 

Catheterism  in  the  female  is  a  very  easy  proceeding 
generally,  and  the  little  papillar  orifice  which  is  situated 
about  an  inch  below  the  clitoris,  in  the  back  part  of  the 
vestibule,  being  detected,  a  straight  instrument  is  readily 
slipped  in  without  exposing  the  patient.  When  any 
difficulty  is  experienced,  it  is  owing  to  some  deviation 
of  the  canal  or  of  the  neck  of  the  bladder,  caused  by  some 
tumor  pressing  upon  the  parts,  which  are  very  mobile. 
Occasionally  fecal  accumulations  in  the  rectum  have 
been  known  to  prevent  micturition,  from  pressing  upon 
the  neck  of  the  bladder,  so  that  in  such  cases  of  retention, 
when  there  is  difficulty  or  impossiblity  of  introducing 
the  female  catheter,  careful  vaginal  examination  must  be 
instituted. 

In  lithotomy  in  the  female  the  vesico- vaginal  operation 
is  the  best,  provided  the  resulting  fistula  be  properly 
treated.  There  is,  however,  a  chance  of  permanent  in- 
continence of  urine,  on  account  of  the  function  of  the 
urethral  sphincter  being  destroyed  by  the  incision  into  the 
neck  of  the  bladder  having  been  made  too  freely.  It  must 
be  borne  in  mind  that  when  the  bladder  is  fully  contract- 
ed, the  septum  between  the  bladder  and  vagina  is  very 

19 


222  LITHOTOMY    IN    THE    FEMALE. 

limited ;  moreover,  in  this  condition  the  openings  of  the 
ureters  are  brought  very  low  down,  and  might  be  im- 
plicated in  the  incision,  which  is  on  no  account  to  be 
transverse.  The  length  of  the  female  urethra  is  about 
an  inch  and  a  half,  curving  slightly  below  the  symphysis, 
with  its  concavity  upwards,  and  having  an  average 
diameter  of  about  a  quarter  of  an  inch,  and  being  highly 
distensible,  very  frequently  calculi  can  be  extracted 
through  it.  There  is  a  good  deal  of  difficulty  experi- 
enced generally  in  using  a  lithotrite  in  the  female  blad- 
der, owing  to  the  fact  of  its  muscular  coat  being  so  thick 
and  strong  and  its  urethral  sphincter  so  weak,  that  the 
urine  or  water  injected  for  the  purpose  of  operation,  es- 
capes past  the  instrument,  leaving  no  cavity ;  moreover, 
the  bladder  forms  a  fossa  on  both  sides  of  the  neck  of 
the  uterus. 

The  arrangement  of  the  perineal  aponeuroses  in  the 
female  is  as  follows :  The  superficial  layer  of  superficial 
fascia  is  continuous  with  that  of  the  nates,  thigh,  and 
abdomen ;  whilst  the  deeper  layer  is  firmly  attached  to 
Poupart's  ligament,  the  ischio-pubic  rami,  and  to  the 
lower  border  of  the  perineal  septum.  These  fasciae  cover 
in  the  labia  majora,  which  are  very  analogous  to  the 
scrotum  in  the  male,  and  being  attached  above  to  the 
external  abdominal  ring,  hernise  pass  in  them,  known  as 
pudendal  or  labial  hernise.  This  deeper  layer  of  fascia  is 
continuous  over  the  ischio-rectal  fossae.  Where  the  two 
layers  of  superficial  fasciae  unite  with  the  lower  borders 
of  the  perineal  septum  to  form  the  perineal  body,  they 
are  joined  by  the  ischio-perineal  ligament,  and  it  forms 
a  support,  or  point  d'appui,  for  the  perineal  muscles. 

Abscesses  in  the  female  perineum  are  of  two  kinds, — 
diffuse,  in  the  superficial  perineal  fascia,  which  readily 


CAVITY    OF    PELVIS.  223 

spread  in  all  directions;  and  circumscribed  abscess  of 
the  vulvo-vaginal  gland,  which  would  be  seen  as  an 
oval  projection  on  the  side  of  the  vestibule. 

The  sacro-coccygeal  region  offers  for  surgical  consid- 
eration a  common  arrest  of  development  of  the  neural 
arches  of  the  sacrum,  constituting  spina  bifida  ;  and  the 
nerves  (cauda  equina)  are  in  this  region  usually  connected 
with  the  sac.  Hence,  if  the  operation  of  puncture  be 
deemed  advisable,  it  should  always  be  made  on  one  side 
of  the  sac,  and  at  its  lowest  part. 

CAVITY  OF  PELVIS. 

The  pelvic  cavity  contains  those  viscera,  the  inferior 
relations  and  apertures  of  which  have  been  described  in 
the  preceding  section — viz.,  the  bladder,  rectum,  and 
vagina,  with  its  appendages,  the  superior  surface  of  the 
perineum  forming  its  inferior  boundary.  The  soft  parts 
lining  its  bony  walls,  the  obturatores  interni,  pyriformes, 
and  levatores  ani  muscles,  are  invested  with  the  reflexion 
of  the  pelvic  fascia,  upon  which  lie  the  peritoneum  and 
subperitorieal  cellular  tissue,  the  arrangements  of  which 
are  of  considerable  importance  surgically.1 

The  pelvic  fascia,  which  is  continuous  with  the  fascia 
iliaca,  is  itself  a  continuation  of  the  transversalis  fascia. 
It  is  attached  to  the  brim  of  the  true  pelvis,  and  round 
the  margin  of  the  obturator  internus  muscle.  At  a 
curved  line  between  the  spine  of  the  ischium  and  the 
pubes,  this  fascia  splits  to  inclose  part  of  the  origin  of 
the  levator  ani  muscle,  the  external  lamina  of  which 
(obturator  fascia)  is  applied  to  the  inner  surface  of  the 


1  The  surgical  anatomy  of  the  uterus  and  ovaries  will  be  better 
studied  in  special  works  on  obstetrics. 


224:  CAVITY    OF    PELVIS. 

obturator  interims  muscle,  and  passing  beneath  the  obtu- 
rator vessels  and  nerve,  completes  the  obturator  canal ;  it 
is  attached  below  to  the  pubic  rami,  where  it  forms  an 
investment  for  the  internal  pudic  vessels  and  nerve.  It 
afterwards  sends  a  thin  fascia,  the  anal,  over  the  lower 


FIG.  39. 


Transverse  section  of  the  pelvis  seen  from  behind,  showing  the  distribution 
of  the  pelvic  fascia.  1.  Bladder.  2.  Vesicula  seminalis  of  one  side  divided.  3. 
Rectum.  4.  Iliac  fascia,  covering  in  the  iliacus  and  psoas  (5),  and  forming  a 
sheath  for  the  external  iliac  vessels  (6).  7.  Anterior  crural  nerve  excluded  from 
the  sheath.  8.  Pelvic  fascia,  splitting  into  the  recto-vesical  and  obturator  layers. 
9.  Recto-vesical  layer,  forming  the  lateral  ligament  of  the  bladder  of  one  side, 
and  a  sheath  to  the  vesical  plexus  of  veins.  10.  A  layer  of  fascia  passing  between 
the  bladder  and  rectum.  11.  A  layer  passing  around  the  rectum.  12.  Levator 
ani.  13.  Obturator  interims,  covered  in  by  the  obturator  fascia,  which  also  forms 
a  sheath  for  the  internal  pudic  vessels  and  nerve  (14).  15.  Anal  fascia,  investing 
the  under  surface  of  the  levator  ani.  Figures  14,  15,  are  placed  in  the  ischio- 
rectal  fossa.  (WILSON.) 

surface  of  the  levator  ani,  which  is  to  be  seen  covering 
it  in  the  ischio-rectal  fossa.  The  internal  lamina  (the 
recto-vesical),  is  continued  over  the  upper  surface  of  the 
levator  ani,  over  the  bladder  and  sides  of  prostate,  and 
lower  end  of  rectum.  The  pubo-prostatic  ligaments  are 
formed  by  two  short  rounded  bands  extending  from  the 
capsule  of  the  prostate  to  the  posterior  aspect  of  the 


CAVITY    OF    PELVIS.  225 

symphysis ;  the  capsule  of  the  prostate  is  formed  from 
the  lateral  attachment  to  it  of  this  fascia,  which  also 
incloses  the  vesico-prostatic  plexus  of  veins.  It  is  this 
portion  of  the  pelvic  fascia  which  it  is  so  important  to 
avoid  dividing  posteriorly  in  the  operation  of  lateral 
lithotomy,  for  by  so  doing  the  urine  would  find  its  way 
into  the  loose  areolar  tissue  between  the  rectum  and  the 
bladder.  The  presence  of  the  prostatic  plexus  of  veins 
is  often  a  serious  source  of  danger.  Posteriorly,  the 
pelvic  fascia  is  continuous  over  the  pyriformis  muscle 
and  sacral  plexus,  being  perforated  by  the  internal  iliac 
artery  and  vein. 

The  inlet  of  the  pelvis  is  somewhat  heart-shaped,  well 
padded  along  its  upper  border  by  the  psoas  and  iliacus 
muscles,  while  posteriorly,  in  the  middle  line,  is  the 
promontory  of  the  sacrum,  or  sacro-vertebral  angle, 
which  can  be  readily  felt  through  the  abdominal  parietes 
in  thin  persons.  Between  the  bladder  and  rectum  is  the 
recto-vesical  pouch,  formed  by  the  pelvic  fascia,  which 
corresponds  posteriorly  where  it  is  broad  to  the  interval 
between  the  iliac  arteries ;  it  is  narrow  in  front  between 
the  rectum  and  the  bladder,  and  extends  as  far  as  the 
vesiculse  seminales,  and,  in  front  and  behind,  to  the  tip 
of  the  coccyx.  Its  relation  to  the  orifice  of  the  anus  is 
important,  and  must  be  referred  to  the  condition  of  the 
bladder,  which,  if  distended,  will  raise  the  pouch  further 
into  the  pelvic  cavity  than  its  usual  level,  which  is  about 
four  inches  above  the  anal  aperture.  Some  coils  of  the 
ileum  and  sigmoid  flexure  of  the  colon  fill  in  the  space. 
The  peritoneum  affording  no  investment  to  the  lower 
end  of  the  rectum,  the  neck,  base,  and  anterior  surface 
of  the  bladder,  or  the  front  and  inferior  portion  of  the 
posterior  wall  of  the  vagina,  permits  of  operative  pro- 


226  SURGICAL    ANATOMY    OF 

ceedings  upon  these  viscera,  without  danger  of  wounding 
it.  The  space  beneath  the  membrane  varies  considerably 
in  different  parts  of  the  floor  of  the  pelvis :  thus,  in  front 
and  at  the  sides  it  is  tolerably  closely  applied  to  the 
underlying  pelvic  fascia,  leaving,  however,  a  considerable 
interspace  in  front  of  the  bladder,  the  point  selected  for 
puncturing  that  viscus  above  the  pubis.  Behind,  and 
above  the  anal  region,  there  is  a  considerable  interval, 
containing  a  great  deal  of  loose  cellular  tissue,  which 
allows  of  the  distension  of  the  rectum,  and  of  the  inter- 
nal iliac  vessels  and  their  branches,  the  ureters,  sacral, 
sympathetic  and  hypogastric  plexuses,  and  the  origin  of 
the  pyriformis  muscle. 

SURGICAL  ANATOMY  OF  THE  BLADDER. 

The  bladder  is  situated  in  the  mesial  line,  beneath  the 
pelvic  fascia  and  peritoneum,  and  lies  obliquely  from 
above  downwards.  Being  attached  to  the  pelvic  floor 
by  its  body  and  base  only,  it  is  freely  movable,  but  the 
urachus  and  anterior  reflexion  of  the  peritoneum  limit 
its  mobility  posteriorly.  When  empty,  the  bladder  lies 
deep  in  the  pelvis  as  a  flattened  sac,  with  its  apex  reach- 
ing up  to  the  symphysis  pubis,  but  when  distended,  its 
relations  are  considerably  altered,  and  are  of  great  sur- 
gical importance.  When  moderately  full,  it  is  round  and 
partially  fills  the  true  pelvis,  but  when  greatly  distended 
it  rises  up  into  the  abdomen,  perhaps  even  reaching  to 
the  umbilicus,  and  becomes  curved  forwards. 

In  children,  as  has  been  before  stated,  it  is  rather  an 
abdominal  than  a  pelvic  viscus,  and  is  conical  in  shape, 
owing  to  the  position  of  the  but  recently  obliterated 
urachus. 


THE    BLADDER.  227 

In  front  of  the  bladder,  between  it  and  the  pubes,  is 
a  quantity  of  lax  cellular  tissue,  the  reflexion  of  the 
peritoneum  from  its  anterior  surface,  and  the  non-attach- 
ment of  this  membrane  to  it  allows  of  its  dilatation,  and 
is  of  great  practical  importance  in  percussing  the  blad- 
der. It  is  here  that  puncture  over  the  pubes  and  the 
"  high "  operation  of  lithotomy  are  practiced,  but  the 
frequency  of  urinary  infiltration  is  greatly  against  the 
latter  proceeding.  Its  posterior  surface  is  entirely  cov- 
ered by  peritoneum,  and  corresponds  in  the  male  to  the 
rectum,  and  in  the  female  to  the  vagina,  and  is  in  relation 
with  some  convolutions  of  the  small  intestine,  which  lie 
in  the  recto-vesical  pouch.  Laterally,  the  peritoneum  is 
applied  to  the  bladder  above  and  behind  the  crossing  of 
the  obliterated  umbilical  artery,  around  which  it  is  re- 
flected. The  vasa  deferentia  pass  along  the  side,  cross 
the  obliterated  umbilical  artery,  and  lie  to  the  inner  side 
of  the  ureter. 

The  base  of  the  bladder  lies  upon  the  anterior  surface 
of  the  rectum,  from  which  it  is  separated  merely  by  a 
thin  layer  of  cellular  tissue  in  the  middle,  and  laterally 
by  the  vesiculse  seminales  and  vasa  deferentia,  the  former 
of  which  are  intimately  adherent  to  it,  and  form  two 
sides  of  a  triangle,  the  base  of  which  is  directed  upwards 
and  backwards,  and  its  apex  towards  the  prostate.  It 
is  at  this  spot  that  puncture  of  the  bladder  by  the  rec- 
tum is  performed.  The  neck  of  the  bladder  is  sur- 
rounded by  the  prostate,  and  is  directed  obliquely  for- 
wards and  downwards. 

The  cavity  of  the  bladder  presents  at  its  base  the  tri- 
gone  vesiece,  an  equilateral  triangle  formed  by  the  oblique 
openings  of  the  ureters  posteriorly,  and  by  the  urethra 
anteriorly.  It  is  through  this  triangular  space  that  the 


228  SURGICAL    ANATOMY    OF 

trocar  enters  in  puncture  per  rectum.     The  trigone  is 
perfectly  smooth,  and  free  from  rugse. 

Immediately  behind  the  trigone,  is  the  deepest  part  of 
the  bladder,  the  bos  fond — not  very  much  marked  in 
children,  but  forming  a  considerable  pouch  in  old  per- 
sons, in  which  the  urine  settles,  causing  considerable 
irritation.  It  is  in  this  pouch  that  calculi  lodge  gener- 
ally. 

In  the  female  the  bladder  is  rather  larger  than  in  the 
male.  It  has  no  has  fond.  The  neck  is  lower,  and  it 
and  the  posterior  portion  of  the  bladder  lie  on  the 
vagina.  Fistulous  openings  occasionally  occur  between 
the  bladder  and  vagina,  or  rectum  and  vagina. 

Internal  Iliac  Artery. — The  artery  of  the  region  is  the 
internal  iliac,  which  furnishes,  with  the  exception  of  the 
middle  sacral,  all  the  vascular  supply  of  the  walls,  the 
soft  parts,  and  viscera.  It  is  given  off  from  the  com- 
mon iliac,  between  the  sacro-iliac  synchondrosis  and  the 
sacro- vertebral  angle. 

After  birth  the  vessel  consists  of  two  trunks,  an  ante- 
rior and  a  posterior — a  subdivision  which  takes  place 
opposite  the  great  sacro-sciatic  notch.  The  branches 
given  off  from  the  anterior  are  those  to  the  bladder  and 
prostate ;  superior  vesical  (the  pervious  portion  of  the 
foetal  hypogastric  artery),  middle  and  inferior  vesical, 
the  middle  hsemorrhoidal  to  the  rectum,  the  obturator, 
the  internal  pudic  and  ischiatic,  and  the  uterine  and  vag- 
inal in  the  female.  Those  given  off  from  the  posterior 
trunk  are  the  gluteal,  ilio-lumbar,  and  lateral  sacral. 
The  gluteal,  ischiatic,  and  internal  pudic  leave  the  pel- 
vis by  the  great  sacro-sciatic  notch,  passing  between  the 
sacral  plexus  of  nerves. 

Relations  of  the  Internal  Iliac  Artery. — The  internal 


THE    BLADDER.  229 

iliac  has,  in  front,  the  peritoneum  and  ureter  (rectum  on 
left  side) ;  externally,  the  psoas  muscle,  and  obturator 
nerve ;  behind,  the  internal  iliac  vein,  lumbo-sacral  nerve, 
and  pyriformis  muscle ;  on  the  right  side  the  vein  is 
more  external. 

Ligature  of  Internal  Iliac  Artery. — This  vessel  is 
reached  by  the  same  incision  as  that  for  the  common 
iliac,  and  the  bifurcation  being  found,  the  space  is  very 
limited  upon  which  the  ligature  can  be  placed ;  the 
short  thick  trunk  passes  downwards  and  backwards 
as  far  as  the  upper  border  of  the  great  sacro-sciatic 
notch. 

The  external  iliac  vein  lies  just  in  the  bifurcation  of 
the  common  into  external  and  internal  iliac,  and  is  liable 
to  be  in  the  way  of  the  needle  in  passing  the  ligature. 
The  lumbar  and  sacral  arteries  chiefly  carry  on  the  cir- 
culation after  its  ligature. 


20 


230  SURGICAL    ANATOMY    OF    THE 


CHAPTER  VI. 

SUKGICAL  ANATOMY  OF  THE   LOWER  EXTREMITY. 

THE  region  of  the  hip  includes,  anteriorly,  the  superior 
femoral  region,  or  the  upper  third  of  the  front  of  the 
thigh,  immediately  below  Poupart's  ligament;  poste- 
riorly, the  gluteal ;  and  internally,  the  ischio-pubie  or 
obturator.  These  several  regions  cover  in  the  articula- 
tion of  the  hip-joint.  The  region  of  the  hip-joint  may 
be  described  as  having  for  its  limits,  the  iliac  crest  and 
sacral  groove,  Poupart's  ligament,  and  below,  a  line  en- 
circling the  limb,  just  below  the  fold  of  the  nates. 

8urfo.ee  Markings. — Anteriorly,  are  the  muscular 
prominences  formed  by  the  tensor  vaginse  femoris  exter- 
nally ;  internally  the  adductors  and  gracilis,  crossed  ob- 
liquely below  by  the  sartorius.  Posteriorly,  is  the  swell 
of  the  gluteus  maximus ;  and  internally,  the  tuberosity 
of  the  ischium,  and  the  rami  of  the  pubes  and  ischium, 
covered  by  their  muscles. 

The  position  of  the  trochanter  major  with  regard  to 
the  several  bony  projections  of  the  region  should  be  care- 
fully studied  in  every  position  of  the  limb.  Its  situa- 
tion is  marked  by  a  deep  depression,  when  the  individual 
is  standing  upright  with  the  heels  together,  and  its  dif- 
ferences of  relation  in  flexion,  extension,  adduction,  and 
abduction,  should  be  compared.  These  relations  are 
obviously  of  the  utmost  importance  in  the  diagnosis  of 
dislocation  or  fracture  connected  with  the  hip-joint. 


SUPERIOR    FEMORAL    REGION.  231 

If  the  exact  relations  of  the  great  trochanter  with  the 
several  osseous  prominences  observable  on  the  pelvis  in 
a  normal  state  be  examined,  it  will  be  noticed  that  if 
the  femur  be  flexed  at  a  right  angle,  and  at  the  same 
time  slightly  adducted,  the  apex  of  the  great  trochanter 
corresponds  with  a  line  drawn  from  the  anterior  superior 
iliac  spine  to  the  tuberosity  of  the  ischium,  and  that  this 
line  divides  the  cotyloid  cavity  (which,  with  respect  to 
the  surface,  may  be  regarded  as  occupying  the  central 
position  between  the  anterior  superior  spine  of  the  ilium, 
the  spine  of  the  pubis,  and  the  tuberosity  of  the  ischium) 
into  two  equal  parts.  This  line  corresponding  to  the 
centre  of  the  cavity,  will  serve  as  a  guide  to  an  appre- 
ciation of  the  extent  of  displacement  in  dislocation. 
Thus  supposing  the  head  of  the  femur  be  placed  behind 
the  cotyloid  cavity,  this  line,  instead  of  corresponding 
with  the  apex  of  the  trochanter  major,  would  correspond 
with  a  point  nearer  its  base.  The  extent  of  the  dis- 
placement, then,  will  be  measured  by  the  prominence  of 
the  great  trochanter  behind  this  line. 


SURGICAL  ANATOMY  OF  THE  SUPERIOR 
FEMORAL  REGION. 

The  superficial  dissection  of  this  region  has  been  al- 
ready described  in  the  chapter  on  inguinal  and  crural 
hernise,  as  it  was  considered  convenient  to  associate  it 
with  the  region  of  the  abdomen  (vide  Abdomen) ;  but 
the  deeper  surgical  relations  are  those  of  the  common 
femoral  and  upper  portion  of  the  superficial  femoral  ves- 
sels, or  Scarpa's  space. 

Scarpa's  Space  or  Triangle. — The  dissection  of  the  parts 
of  femoral  hernia  having  been  completed,  and  the  fascia 


232  SURGICAL    ANATOMY    OF    THE 

lata  detached,  a  triangular  space  is  exposed  which  has 
for  its  limits  the  following  :  its  base,  the  crural  arch  ;  its 
external  boundary,  the  sartorius  ;  its  internal,  the  adduc- 
tor longus.  In  the  centre  of  this  triangle  so  formed, 
passing  from  the  middle  of  its  base  to  the  apex  (the 
meeting  of  the  sartorius  and  adductor  longus),  lie  the 
femoral  vessels.  The  floor  upon  which  they  rest  is  formed 
from  without  inwards  by  the  iliacus,  psoas,  pectineus, 
adductor  longus,  and  part  of  the  adductor  brevis  mus- 
cles. The  anterior  crural  nerve  lies  in  the  furrow  be- 
tween the  iliacus  and  psoas  muscles.  The  femoral  artery 
lies  external  to  and  a  little  superficial  to  its  vein.  The 
sheath  of  the  femoral  vessels,  which  has  been  before  de- 
scribed (vide  Crural  Hernia),  ceases  at  the  division  of  the 
common  femoral  into  superficial  and  deep,  and  is  formed 
anteriorly  by  a  prolongation  of  the  fascia  transversalis, 
and  posteriorly  by  the  fascia  iliaca,  which  furnish  septa 
between  the  common  femoral  vessels.  The  inner  margin 
of  the  psoas  separates  the  artery  from  the  hip-joint,  and 
passing  behind  the  sheath  is  the  branch  of  the  anterior 
crural  nerve  to  the  pectineus.  Lying  on  the  pectineus, 
and  outer  surface  of  the  adductor  longus,  are  the  deep 
external  pudic  vessels,  branches  of  the  common  femoral, 
beneath  the  pubic  portion  of  the  fascia  lata. 

On  the  outer  side  of  the  sartorius  is  the  tensor  vaginae 
femoris,  passing  obliquely  outwards,  and  backwards,  to 
be  inserted  into  the  fascia  lata ;  and  between  it  and  the 
sartorius  is  the  upper  portion  of  the  rectus  femoris,  with 
some  branches  of  the  external  circumflex  vessels  passing 
outwards  into  its  substance.  Passing  inwards  towards 
the  articulation  will  be  met  with,  from  without,  inwards, 
beneath  the  sartorius  and  vessels,  the  lower  portion  of 
the  combined  tendons  of  the  psoas  and  iliacus  in  their 


SUPERIOR    FEMORAL    REGION.  233 

sheath ;  a  cellular  interspace  between  them  and  the  outer 
border  of  the  pectineus,  in  which  lie  the  internal  circum- 
flex vessels,  the  pectineus,  and  the  adductor  brevis,  also 
separated  by  a  slight  interval.  Beneath,  the  upper  por- 
tion of  the  rectus  and  the  external  circumflex  vessels, 
the  upper  part  of  the  vasti,  the  neck  of  the  femur,  and 
the  anterior  portion  of  the  articulation.  Immediately 
behind  the  psoas  and  iliacus  tendon  and  the  pectineus, 
are  large  bursae  separating  them  from  the  joint.  Beneath 
the  pectineus  and  adductor  brevis  are  the  obturator  ves- 
sels and  nerve,  the  obturator  externus,  and  portion  of 
the  adductor  magnus  muscles. 

Femoral  Artery  in  Soarpa's  Space. — The  vessel  is  a 
continuation  of  the  external  iliac,  and  enters  the  space 
below  Poupart's  ligament,  at  a  point  midway  between 
the  anterior  superior  spine  of  the  ilium  and  the  symphy- 
sis  pubis,  and  it  lies  in  the  crural  sheath  for  about  an 
inch  and  a  half  or  two  inches,  which  sheath  separates  it 
from  the  fascia  lata  and  inguinal  glands. 

The  common  femoral  vein  lies  to  its  inner  side  above, 
but  gets  behind  it  lower  down.  The  anterior  crural 
nerve  lies  about  half  an  inch  external  to  it.  It  lies  at 
first  on  the  psoas  and  afterwards  on  the  pectineus,  but 
separated  from  it  by  the  femoral  vein  and  profunda  ves- 
sels. It  usually  gives  off  four  superficial  branches — 
the  superficial  epigastric,  circumflex  iliac,  and  the  super- 
ficial and  deep  external  pudic.  The  profunda  or  deep 
femoral  generally  arises  from  the  outer  and  back  part  of 
the  common  trunk,  about  an  inch  and  a  half  or  two 
inches  below  the  crural  arch ;  at  its  commencement  the 
vessel  is  on  the  outside  of  the  femoral  vessels ;  but  it 
soon  passes  behind,  and  finally  reaching  the  inside, 
courses  downwards  and  backwards  among  the  adductor 


234 


SURGICAL    ANATOMY    OF    THE 


FIG.  40. 


muscles.  It  rests  on  the 
iliacus,  pectineus,  and  ad- 
ductor brevis,  and  passing 
between  the  adductor  lon- 
gus  and  magntis,  terminates 
in  a  small  twig  that  pierces 
the  magnus.  The  pro- 
funda  gives  off,  the  external 
circumflex,  which  arising 
from  its  outer  side,  passes 
outwards  between  the  bran- 
ches of  distribution  of  the 
anterior  crural  nerve,  below 
the  sartorius  and  rectus, 
and  divides  into  three  se- 
ries of  branches, — ascend- 
ing, descending,  and  trans- 
verse. The  internal  circum- 
flex is  given  off  from  the 
inner  and  back  part  of  the 
profunda,  passes  between 
the  pectineus  and  psoas 
muscles,  and  opposite  the 
tendon  of  the  obturator  ex- 
ternus,  it  gives  off  two 
branches :  one  an  ascending, 
inosculating  with  the  obtu- 


Superficial  dissection  of  the  front  of  the  thigh.  1.  Poupart's  ligament.  2.  Su- 
perficial branches  of  femoral  artery.  3.  External  cutaneous  nerve.  4.  Femoral 
artery.  5,  5,  5.  Middle  cutaneous  nerve.  6.  Femoral  vein.  7,  7,  7.  Outer  divi- 
sion of  internal  cutaneous  nerve.  8,  8,  8.  Inner  division  of  ditto.  9.  Branch  to 
sartorius.  10.  Saphena  vein.  11.  Sartorius  plexus.  12.  Cutaneous  branch  of 
obturator  nerve.  13.  Patellae.  14.  Patellar  branch  of  long  saphena.  16.  Long 
or  internal  saphenous  nerve.  (HEATH.) 


SUPERIOR    FEMORAL    REGION.  235 

rator,  and  a  descending,  muscular ;  and  the  vessel  itself 
passes  into  the  gluteal  region  between  the  quadratus 
feraoris  and  adductor  magnus,  inosculating  with  the  is- 
chiatic,  external  circumflex,  and  superior  perforating 
vessels.  The  perforating  arteries  :  The  first  is  generally 
given  off  from  the  profunda,  just  above  the  tendon  of 
the  adductor  brevis,  between  it  and  the  pectineus,  and 
pierces  the  adductor  magnus ;  the  second  pierces  the  ad- 
ductor brevis  and  magnus ;  and  the  third  is  given  off 
below  the  adductor  brevis,  and  pierces  the  adductor 
magnus.  The  inosculations  of  these  vessels  will  be  con- 
sidered in  the  description  of  the  thigh  and  buttock. 

Compression  of  the  femoral  artery  in  the  upper  third 
is  easily  effected,  either  just  as  it  passes  over  the  pubes, 
where  the  pressure  should  be  made  obliquely  backwards, 
on  account  of  the  surface  of  .the  bone  being  inclined 
slightly  forwards,  or  just  below  Poupart's  ligament,  at  a 
point  where  it  is  very  superficial,  being  separated  from 
the  acetabulum  and  neck  of  femur  by  the  psoas  in  ex- 
tension of  the  thigh. 

Ligature  of  the  Femoral  Artery  in  Scarpa's  Space. — 
Except  in  the  case  of  a  wound,  the  common  femoral  is 
rarely  tied,  owing  to  the  number  of  small  superficial  and 
muscular  branches,  affording  but  little  chance  of  a  good 
coagulum  being  made.  For  popliteal  aneurism,  &c., 
the  superficial  femoral  is  tied  just  at  the  point  before  it 
passes  beneath  the  sartorius.  (By  the  superficial  femoral 
is  meant  that  portion  of  the  vessel  between  the  giving  off 
of  the  profunda  and  the  point  where  it  becomes  pop- 
liteal.) 

The  knee  being  slightly  bent,  an  incision  of  about  two 
or  three  inches  in  length  is  to  be  made  over  the  course 
of  the  artery,  dividing  the  skin,  superficial  fascia,  and 


236  SURGICAL    ANATOMY    OF 

fat.  Next  the  fascia  lata  is  to  be  divided,  when  the 
oblique  fibres  at  the  edge  of  the  sartorius  will  be  seen, 
and  which  are  to  be  drawn  aside  in  order  to  give  room. 
Some  branches  of  the  anterior  crural  nerve  are  generally 
spread  out  over  the  course  of  the  vessel,  and  occasionally 
the  internal  saphena  nerve  crosses  it  at  this  point.  The 
sheath  is  next  to  be  opened,  only  so  much  so  as  to  allow 
of  the  easy  passage  of  the  aneurism  needle  round  the 
vessel,  and  to  avoid  wounding  more  of  the  vasa  vasorum 
than  is  absolutely  necessary,  thus  interfering  with  the 
nutrition  of  its  coats.  The  needle  should  be  passed  from 
within  outwards. 

Collateral  Circulation  after  Ligature  of  the  Femoral 
Artery  in  Sear  pa's  Space. — The  external  circumflex  from 
the  profunda  anastomoses  with  the  gluteal  and  circum- 
flex iliac,  the  internal  circumflex  with  the  obturator 
ischiatic,  and  superior  perforating,  and  the  vessels  in  the 
popliteal  space  with  the  comes  nervi  ischiadici. 

The  tumors  in  Scarpa's  space,  which  might  be  mis- 
taken for  aneurisms,  are  enlarged  glands,  cysts,  psoas 
abscess,  enlargement  of  the  bursa  below  the  psoas,  and 
hernia.  Femoral  hernise  lie  to  the  inner  and  upper  side 
of  the  vessels;  psoas  abscesses  point  external  to  them. 
Inguinal  hernise  may  be  mistaken  for  crural,  owing  to 
the  circumstance  that  adhesions  taking  place  from  any 
cause  between  the  aponeuroses  may  divert  their  course ; 
it  is  far  more  common  for  crural  hernise  to  resemble  in- 
guinal (vide  Crural  Hernia). 

SURGICAL  ANATOMY  OF  THE  GLUTEAL  REGION. 

This  region  is  of  great  surgical  importance  from  its 
intimate  relations  with  the  hip-joint,  and  the  control  the 
muscles  have  over  its  several  movements ;  it  has  for  its 


THE    GLUTEAL    REGION.  237 

limits,  in  front,  the  anterior  superior  spine  of  the  ilium, 
and  the  margin  of  the  tensor  vaginae  femoris;  superiorly 
the  crest ;  posteriorly  the  posterior  superior  spine  of  the 
ilium,  the  sacrum,  and  the  middle  line  of  the  body ; 
below  the  tuberosity  of  the  ischium,  and  fold  of  the  nates. 

Dissection. — On  removing  the  skin,  there  is  a  consid- 
erable amount  of  fat,  particularly  over  the  tuberosity  of 
the  ischium,  in  which  lie  a  number  of  cutaneous  nerves, 
supplying  the  integument ;  the  fascia  lata,  which  is  thin 
over  the  gluteus  maximus,  and  very  thick  in  front  over 
the  gluteus  medius,  to  which  it  gives  origin;  next,  the 
gluteus  maximus,  and  the  anterior  and  superior  portion 
of  the  medius. 

Parts  beneath  the  Gluteus  Maximus. — Beneath  the 
gluteus  maximus  lie,  first  of  all,  a  fibro-cellular  layer, 
continuous  with  the  subperitoneal  cellular  tissue  through 
the  great  sacro-sciatic  notch,  a  portion  of  the  gluteus 
medius,  sacro-sciatic  ligaments,  pyriformis  muscle,  with 
the  sciatic  vessels  and  nerves  emerging  below  its  inferior 
border;  the  obturator  internus,  with  its  satellite  muscles, 
the  gemelli ;  the  internal  pudic  vessels  and  nerve  with 
the  nerve  to  the  obturator  internus,  the  quadratus  femoris, 
the  tuberosity  of  the  ischium  with  the  origin  of  the  ham- 
string muscles,  the  great  trochanter  covered  by  a  large 
bursa  mucosa,  which  separates  it  from  the  gluteus  maxi- 
mus, and  part  of  the  origin  of  the  vastus  internus,  the 
superficial  gluteal  vessels,  and  the  anastomoses  of  the 
external  circumflex  with  the  gluteal  vessels,  the  gluteus 
minimus  muscle,  the  posterior  part  of  the  articulation  of 
the  hip-joint ;  and  beneath  the  quadratus  femoris,  the 
obturator  externus  and  the  anastomosing  branch  of  the 
internal  circumflex. 

The  gluteal  artery,  generally  the  larger  terminal  branch 


238  SURGICAL    ANATOMY    OF 

of  the  posterior  division  of  the  internal  iliac,  passes  out 
of  the  pelvis,  at  the  upper  part  of  the  great  sacro-sciatic 
notch,  and  lies  between  the  gluteus  minimus  and  pyri- 
formis.  It  may  be  the  seat  of  aneurism,  either  idio- 
pathic  or  traumatic,  and  the  vessel  in  either  case  may  be 
readily  reached  in  actual  practice,  without  attendance  to 
the  somewhat  complicated  directions  given  for  finding 
it ;  in  the  former  case  the  swelling  caused  by  the  posi- 
tion of  the  sac,  and  in  the  latter  the  direction  of  the 
already  existing  external  wound,  would  guide  the  sur- 
geon. 

The  internal  pudic  artery  lies  very  deep  in  the  gluteal 
region,  and  having  escaped  between  the  pyriformis  and 
levator  ani,  emerges  from  the  pelvis  at  the  great  sacro- 
sciatic  notch,  and  winds  round  the  spine  of  the  ischium 
accompanied  by  its  nerve ;  again  reaching  the  pelvis  at 
the  lesser  sacro-sciatic  notch,  it  lies  on  the  inner  surface 
of  the  ischium,  and  is  there  covered  by  a  process  of  the 
obturator  fascia  (vide  Perineum). 

The  great  sciatie  nerve  emerges  from  the  greater  notch 
at  its  lower  portion,  and  lies  exactly  between  the  tuber- . 
osity  of  the  ischium  and  the  great  trochanter. 

The  intermuscular,  cellulo-fatty  membranes,  which 
are  so  extensive  in  the  gluteal  region,  freely  intercom- 
municate with  those  within  the  pelvis,  and  readily  ex- 
plain the  passage  of  pus  either  from  or  into  its  cavity. 
Sciatic  hernice  occasionally  exist,  a  portion  of  intestine 
passing  down  through  the  greater  sacro-sciatic  foramen, 
and  having  the  vessels  posterior  to  its  sac. 

The  bursa  over  the  great  trochanter  is  sometimes  the 
seat  of  abscess,  which  may  be  mistaken  for  diseases  of 
the  hip-joint. 

The  obturator  or  ischio-pubic  region  forms  the  inner 


THE    GLUTEAL    REGION.  239 

boundary  of  the  region  of  the  hip,  and  comprises  the 
obturator  foramen,  the  structures  covering  it  on  either 
surface,  and  the  parts  immediately  adjacent.  The  bony 
prominences  are  easily  felt;  they  are  the  pubic  space  and 
horizontal  ramus  of  the  pubes  anteriorly,  and  the  de- 
scending ram  us  and  tuberosity  of  the  ischium  internally 
and  behind.  The  anterior  surface  consists  of  the  gra- 
cilis,  pectineus  and  adductors,  beneath  which  is  the  ob- 
turator interims.  The  obturator  foramen  is  not  entirely 
filled  in  by  the  membrane,  being  wanting  just  below  the 
groove  through  which  the  obturator  artery  and  nerve 
pass.  Attached  to  the  inner  or  pelvic  surface  of  the 
membrane  and  to  the  bone  around,  is  the  obturator*  in- 
tern us,  having  the  obturator  fascia  below,  between  it  and 
the  levator  ani,  and  the  peritoneum  above;  it  is  inti- 
mately connected  with  the  margins  of  the  obturator 
membrane,  and  assists  in  forming  the  obturator  canal. 
This  obturator  canal  is  about  three-quarters  of  an  inch 
in  length,  and  directed  obliquely  from  above  downwards, 
and  from  without  inwards. 

Obturator  Hernia. — Occasionally  a  hernia  protrudes 
through  the  canal,  and  forms  a  swelling  in  the  adductor 
or  pubic  region,  emerging  upon  the  thigh,  below  the 
horizontal  ramus  of  the  pubes,  to  the  inner  side  of  the 
capsule  of  the  hip-joint,  having  the  femoral  vessels  in 
front,  and  a  little  to  the  outer  side,  the  tendon  of  the 
adductor  longus  to  the  inner  side,  and  behind,  the  pec- 
tineus muscle.  The  obturator  vessels  and  nerve  also 
pass  through  it  to  the  thigh,  and  the  pressure  exerted  by 
the  hernia  upon  the  nerve  induces  pain  in  those  regions 
to  which  it  is  supplied,  and  is  a  feet  of  importance  in 
diagnosis. 


240  SURGICAL    ANATOMY    OP 

SURGICAL  ANATOMY  OF  THE  HIP-JOINT. 

The  hip-joint  itself  lies  inclosed  in  the  foregoing 
regions,  which  have  been  described  from  the  surface  in- 
wards ;  and  before  entering  upon  a  description  of  the 
joint  itself,  it  is  important  to  examine  the  relations  of  the 
muscles  to  the  articulation,  and  their  control  over  its 
movements,  in  order  to  understand  the  exact  position  of 
the  head  of  the  femur  in  the  several  dislocations  to  which 
the  joint  is  liable,  and  their  action  upon  the  upper  por- 
tion of  the  thigh  bone  in  fractures. 

Immediately  in  front  of  the  joint  is  the  tendon  of  the 
psoas  and  iliacus  (separated  from  the  capsular  ligament 
by  a  bursa) ;  above  is  the  reflected  tendon  of  the  rectus 
femoris  and  the  glutens  minimus,  closely  interwoven 
with  the  capsule ;  internally  the  obturator  externus  and 
pectineus ;  posteriorly  the  pyriformis,  obturator  interims, 
and  gemelli,  tendon  of  obturator  externus,  and  quad- 
ratus  femoris  (vide  Fig.  40).  All  these  muscles  are  in 
absolute  relation  with  the  capsular  ligament,  and  are 
covered  in  by  the  superficial  muscles  already  described. 

Being  an  enarthrodial  joint,  the  movements  of  which 
it  is  capable  are  very  extensive :  Flexion,  which  is  pro- 
duced by  the  psoas  and  iliacus,  sartorius  and  rectus 
femoris.  Extension,  by  the  hamstrings  and  some  fibres 
of  the  glutens  maximus.  In  both  these  movements  the 
neck  of  the  femur  rotates  on  its  axis,  whilst  the  inferior 
extremity  of  the  thigh  bone  describes  an  arc  of  a  circle, 
directly  backwards  and  forwards.  Adduction  is  per- 
formed by  the  pectineus,  adductors  and  gracilis.  In 
this  movement  the  shaft  of  the  femur  is  adducted  to  the 
middle  line  of  the  body,  and  its  neck  is  lowered.  Ab- 
duction, by  the  glutens  medius  and  minimus,  and  the 


THE    HIP-JOINT.  241 

tensor  vaginae  feraoris.  The  neck  of  the  femur  is  raised. 
Rotation  outwards,  in  which  the  trochanter  major  is 
thrown  backwards  and  the  foot  outwards,  by  the  glutens 
maximus  and  medius,  pyriforrnis,  obturators,  and  quad- 
ratns  femoris.  Internal  rotation.,  when  the  great  tro- 
chanter is  thrown  forwards  and  the  foot  inwards,  by  the 
anterior  fibres  of  the  gluteus  medius  and  the  gluteus 
minimus. 

It  will  be  seen  that  the  greater  part  of  these  muscles 
are  external  rotators,  and  it  has  been  considered  that  this 
fact  explains  the  corresponding  rotation  of  the  thigh  in 
fracture  of  the  neck  of  that  bone,  but  it  is  much  more 
probable  that  the  eversion  of  tbe  limb  is  due  simply  to 
its  own  weight.  External  rotation,  however,  is  of  no 
diagnostic  value  in  fracture  of  the  neck,  unless  accom- 
panied by  actual  shortening  of  the  limb. 

The  trochanter  major  is  the  great  lever  into  which  are 
inserted  the  rotator  muscles  of  the  hip-joint,  and  is  sep- 
arated from  the  integuments  by  the  anterior  edge  of  the 
tendon  of  the  gluteus  maximus,  beneath  which  is  a  large 
bursa.  Its  variable  position  is  readily  seen  in  the  seve- 
ral movements  of  the  hip,  describing  the  arc  of  a  circle, 
owing  to  its  continuity  with  the  neck  of  the  femur. 
When  the  neck  of  the  femur  is  fractured,  the  trochanter 
major  rotates  in  the  axis  of  the  bone,  and  in  cases  of  dis- 
location, or  suspected  dislocation,  measurements  of  its 
distance  from  the  anterior  superior  iliac  spine  must  be 
carefully  compared  with  similar  measurements  taken  on 
the  opposite  side  of  the  body.  The  position  of  the  tro- 
chanter minor,  which  lies  just  below  the  neck,  at  the  su- 
perior and  inferior  aspect  of  the  femur,  is  of  importance 
to  the  surgeon  in  performing  amputation  at  the  articu- 
lation, as  the  knife  is  liable  to  be  locked  in  it  unless  care 
be  taken  to  pass  it  well  behind. 


242  SURGICAL    ANATOMY    OF 

The  capsular  ligament  is  the  thickest  and  strongest  in 
the  body,  and  particularly  that  anterior  portion  known 
variously  as  the  ilio-femoral  band,  or  the  inverted  Y- 
shaped  ligament  of  Bigelow,  of  which  the  tail  of  the  Y 
is  attached  to  the  anterior  inferior  spinous  process  of  the 
ilium,  and  the  fork  to  the  root  of  the  great  trochanter 
and  intertrochanteric  line.  It  has  been  shown  by  Bige- 
low that  this  thickened  portion  of  the  capsule  is  the  chief 
agent  in  producing  the  characters  of  the  regular  varieties 
of  luxation.  When  it  is  ruptured  in  dislocation,  it  is 
almost  always  at  its  base,  and  so  strong  is  it  in  some 
instances,  that  the  margins  of  the  cotyloid  cavity  have 
given  way. 

The  neck  of  the  femur  varies  as  regards  its  obliquity  to 
the  shaft  with  the  age  of  the  individual.  Before  puberty 
it  is  very  oblique,  and  almost  in  a  continuous  axis  with 
the  shaft ;  in  the  adult  male  it  is  at  an  obtuse  angle  with 
it,  and  directed  upwards,  inwards,  and  forwards,  whilst 
in  old  persons  it  becomes  horizontal. 

The  head  of  the  femur  presents  a  smooth  ball,  of  very 
regular  form,  somewhat  more  than  hemispherical,  di- 
rected upward,  inward,  and  a  little  forward,  for  articula- 
tion with  the  acetabulum.  It  has  a  separate  point  of 
ossification,  becoming  united  to  the  shaft  at  the  eighteenth 
year. 

The  synovial  membrane  covers  all  that  portion  of  the 
neck  within  the  joint,  and  is  reflected  on  to  the  internal 
surface  of  the  capsule,  ensheathing  the  ligamentum  teres, 
and  often  communicating  anteriorly  with  the  bursa  be- 
neath the  psoas  and  iliacus. 

The  cotyloid  cavity  is  deepened  by  the  cotyloid  liga- 
ment, rendered  continuous  below  by  the  transverse  liga- 
ment, beneath  which  the  nutrient  vessels  pass  to  the  joint. 


THE    HIP-JOINT.  243 

.The  ligamentum  teres  is  attached  by  its  apex  into  a 
fossa  just  behind  and  below  the  centre  of  the  globular 
head  of  the  bone,  and  by  its  base  to  the  margins  of  the 
notch  at  the  bottom  of  the  acetabulum,  and  its  office  is 
to  check  external  rotation  and  adduction  when  the  thigh 
is  flexed,  thus  assisting  in  the  prevention  of  dislocation 
of  the  head  forwards  and  outwards.  The  bottom  of  the 
cotyloid  cavity  is  very  thin,  and  is  liable  to  perforation 
in  caries,  in  which  case  the  pus  invades  the  pelvic  cavity. 
It  may  be  opened  by  the  point  of  the  knife  in  amputa- 
tion through  the  hip-joint,  or  in  the  subsequent  gouging 
after  resection,  unless  care  be  taken.  It  is  a  somewhat 
remarkable  fact  that  after  the  operation  of  disarticula- 
tion,  or  in  the  case  of  old  unreduced  dislocation,  the 
cavity  contracts. 

The  vessels  which  supply  the  articulation  are  the  obtur- 
ator, ischiatic,  internal  circumflex,  and  gluteal ;  and  the 
nerves  are  from  the  great  sciatic,  obturator,  and  accessory 
obturator,  and  they  enter  it  either  by  means  of  the  notch, 
or  through  the  ligamentum  teres. 

Dislocation  of  the  Head  of  the  Femur. — With  regard  to 
the  displacements  of  the  head  of  the  femur  in  dislocation, 
none  of  the  muscles  of  the  gluteal  region  probably  exert 
any  influence  excepting  the  obturator  interims,  the  mus- 
cular substance  of  which  is  so  mixed  with  tendinous 
structure  as  to  give  it  great  strength ;  and  when  in  a 
state  of  contraction  it  may  be  regarded  as  an  accessory 
ligament  to  the  joint. 

The  regular  dislocations  of  the  head  of  the  thigh  bone 
are — (1)  upwards,  on  to  the  dorsum  ilii ;  (2)  backwards, 
into  the  great  sciatic  arch  ;  (3)  downwards,  into  the  ob- 
turator foramen,  and  (4)  forwards,  on  to  the  pubes.  In 
the  first  form  the  limb  is  shortened  from  one  to  two  and 


244  SURGICAI^    ANATOMY    OF 

a  half  inches,  and  slightly  bent,  the  knee  resting  on  the 
opposite  thigh,  and  the  great  toe  upon  the  opposite  in- 
step, the  head  of  the  femur  being  felt  beneath  the  glutei. 
In  the  second  form  the  limb  is  shortened  for  about  half 
an  inch,  and  the  thigh  turned  inwards  and  slightly  flexed, 
the  ball  of  the  great  toe  lying  on  the  base  of  the  meta- 
carpal  bone  of  the  opposite  foot,  and  the  head  of  the 
thigh  bone  protruding  below  and  behind  the  tendon  of 
the  obturator  internus.  In  the  third  form,  the  limb  is 
lengthened  for  about  one  or  two  inches,  the  thigh  is 
flexed,  and  abducted  and  advanced  in  front  of  the  oppo- 
site one,  the  toes  pointing  downwards  and  forwards,  and 
the  trunk  flexed  on  account  of  the  tension  on  the  psoas 
and  iliacus  muscle.  In  the  fourth  form  the  limb  is 
shortened,  rotated  outwards,  and  the  head  of  the  bone 
felt  on  the  pubes,  just  below  Poupart's  ligament.  The 
limb,  moreover,  is  abducted,  and  the  foot  points  directly 
outwards. 

The  action  of  the  muscles  is  well  marked  in  cases  of 
fracture,  either  of  the  neck  of  the  femur  internal  to  the 
capsule,  or  just  below  the  trochanter,  as  far  as  the  upper 
fragment  is  concerned.  In  the  former  case,  which  is  the 
fracture  of  old  age,  and  is  a  result  of  the  slightest  mishap, 
there  is  eversion  of  the  limb,  produced,  according  to  some 
authorities,  by  the  action  of  the  external  rotators,  but  far 
more  likely  by  the  weight  of  the  foot  alone,  and  shorten- 
ing, which  is  produced  by  the  action  of  the  glutei,  rectus, 
and  hamstrings.  In  the  case  of  fracture  below  the  tro- 
chanters,  a  result  of  direct  violence,  the  upper  fragment 
is  pulled  forwards  by  the  psoas  and  iliacus,  everted  and 
drawn  outwards  by  the  external  rotators.  There  is  short- 
ening of  the  limb  beyond  the  point  of  fracture,  owing  to 
the  action  of  the  rectus  in  front  and  the  hamstrings  be- 


THE    HIP-JOINT. 


245 


hind,  and  the  upper  end  is  thrown  outwards  and  the 
lower  inwards,  and  everted  by  the  adductors. 

The  most  important  operations  in  this  region  are  am- 
putation through  the  hip-joint,  and  excision  of  the  head  of 


FIG.  41. 


Section  through  the  hip  and  gluteal  region.  1.  Glutens  maximus.  2.  Gluteus 
medius.  3.  Gluteus  minimus.  4.  Pyriformis.  5.  Great  sciatic  nerve  and  ischi- 
atic  vessels.  6.  Obturator  interims.  7.  Gemelli.  8.  Biceps.  9.  Quadratus  fem- 
oris.  10.  Sartorius.  11.  Reflected  tendon  rectus.  12.  Psoas  and  iliacus  and 
bursa.  13.  Anterior  crural  nerve.  14.  Common  femoral  artery.  15.  Common 
femoral  vein.  16.  Profunda  vessels.  17.  Gracilis.  18.  Semi-mem  bran  osus.  19. 
Adductor  brevis.  20.  Semi-tendinosus.  21.  Obturator  externus.  22.  Adductor 
longus.  23.  Adductor  magnus.  (Altered  from  BERAUD.) 

the  femur.  In  the  operation  of  amputation.,  supposing 
the  most  rapid  method,  namely,  that  by  anterior  and 
posterior  flaps,  be  performed,  the  anterior  flap  can  be 
cut,  and  the  articulation  opened  by  the  first  thrust  of  the 

'21 


246  SURGICAL    ANATOMY    OF    THE 

knife,  if  a  point  midway  between  the  anterior  superior 
spinous  process  of  the  ilium  and  the  trochanter  major  be 
taken  for  entering  the  instrument,  and  its  point  be  in- 
sinuated onwards  towards  the  capsule,  transfixing  it,  and 
directed  downwards,  forwards,  and  inwards,  to  a  point 
just  in  front  of  the  tuberosity  of  the  ischium  ;  the  knife 
is  then  to  cut  the  anterior  flap  from  the  front  of  the  thigh, 
and  an  assistant  is  to  help  the  operator  by  rotating  the 
limb  forcibly  outivards,  so  as  to  bring  the  globular  head 
of  the  femur  and  its  attached  ligamentum  teres  towards 
the  surface ;  the  ligament  and  capsule  being  divided,  the 
assistant  rotates  the  limb  inwards,  at  the  same  time  draw- 
ing it  towards  himself,  so  that  the  operator's  knife,  after 
cutting  through  the  posterior  portion  of  the  capsule,  may 
clear  the  trochanter  major,  and  fashion  the  hinder  flap. 

Structures  Divided  in  Amputation  through  the  Hip-joint 
by  the  Antero-posterior  Flaps. — In  the  anterior,  integu- 
ment, fasciae,  and  superficial  vessels,  sartorius,  anterior 
crural  nerve,  femoral  vessels,  rectus,  tensor  fasciae,  ilia- 
cus  and  psoas,  portion  of  gracilis,  adductor  longus,  ad- 
ductor brevis,  pectineus,  and  profunda  vessels,  and  part 
of  obturator  externus  and  glutei,  with  superior  gluteal 
and  external  circumflex  vessels  and  nerves,  capsular  lig- 
ament, and  ligamentum  teres.  In  the  posterior,  part  of 
the  gracilis,  adductor  longus  and  brevis,  and  the  adduc- 
tor magnus  and  pectineus,  internal  circumflex  artery, 
obturator  nerve,  quadratus  femoris,  part  of  obturator  ex- 
ternus, obturator  internus  and  gemelli,  the  hamstring 
muscles,  sciatic  vessels  and  nerves,  part  of  glutens  mini- 
mus and  medius,  and  the  gluteus  maximus,  with  its  ves- 
sels, and  the  integuments  of  the  buttock. 

Excision  of  the  Hip-joint. — The  joint  may  be  exposed 
either  by  a  straight,  curved,  or  T-incision,  according  to 


MIDDLE    FEMORAL    REGION.  247 

circumstances ;  the  straight  portion  should  commence 
just  below  the  anterior  superior  spinous  process  of  the 
ilium,  and  be  carried  vertically  over  the  trochanter 
major,  and  the  following  structures  divided  :  the  gluteus 
medius  and  minimus,  obturator  internus  and  gemelli, 
obturator  externus,  pyriformis  muscles,  and  the  capsular 
ligament.  The  head  of  the  bone  is  protruded  through 
the  wound  by  bringing  the  knee  of  the  affected  side 
forcibly  across  the  opposite  thigh,  with  the  toes  everted. 
The  bone  is  to  be  divided  below  the  level  of  the  tro- 
chanter major.  A  more  scientific  proceeding  is  to  sepa- 
rate the  periosteum  entire  from  the  trochanter,  leaving 
the  attachment  of  the  muscles ;  by  this  means  they  retain 
in  a  great  measure  their  proper  action,  and,  moreover, 
new  bone  is  thrown  out. 


SURGICAL  ANATOMY  OF  THE  MIDDLE  FEMORAL 
REGION. 

The  limits  of  this  region  may  be  indicated  superiorly 
by  a  line  drawn  round  the  thigh  at  the  fold  of  the  nates, 
and  inferiority  by  one  drawn  round  the  lower  portion  of 
the  thigh  at  about  an  inch  above  the  patella ;  it  has 
the  form  of  a  truncated  cone,  with  the  base  directed  up- 
wards. 

Surface  Markings. — Anteriorly,  the  prominences  of  the 
oblique  crossing  of  the  sartorius,  extending  from  the  an- 
terior iliac  spine  to  the  inner  side  of  the  knee,  and  of  the 
tensor  fasciae  femoris,  inclosing  a  triangular  interval,  in 
which  is  the  commencement  of  the  quadriceps  extensor, 
which  forms  two  curved  muscular  masses,  fuller  inferi- 
orly,  and  inclosing  a  small  triangular  interval  immedi- 
ately above  the  patella,  corresponding  to  its  tendon  of 


248  SURGICAL    ANATOMY    OP    THE 

insertion.  Posteriorly,  the  surface  is  convex,  and  infe- 
riorly  is  seen  the  divergence  of  the  muscular  masses 
which  form  the  popliteal  space.  Externally,  the  surface 
is  convex,  and  separated  from  the  posterior  by  a  deep 
furrow,  marking  the  position  of  the  external  intermus- 
cular  aponeurosis.  Internally  and  superiorly  is  the 
superior  femoral  region  and  Scarpa's  space ;  the  middle 
of  this  surface  is  flat,  and  indicates  the  position  of  the 
crossing  of  the  sartorius ;  inferiorly  is  a  large  oval  emi- 
nence, due  to  the  vastus  internus. 

The  course  of  the  femoral  artery,  which  is  seen  pulsat- 
ing in  Scarpa's  space,  is  indicated  by  a  line  drawn  from 
the  centre  of  Poupart's  ligament  to  a  point  just  behind 
the  internal  condyle  of  the  femur. 

Dissection. — The  skin  of  this  region  is  very  thick  pos- 
teriorly, thinner  in  front  and  internally,  and  freely  sup- 
plied with  sebaceous  glands  in  the  upper  and  inner  por- 
tion near  the  groin. 

The  subcutaneous  cellular  tissue  generally  contains  a 
good  deal  of  fat,  and  the  superficial  veins,  nerves,  and 
lymphatics  lie  in  it.  The  most  important  superficial 
vessel  is  the  internal  saphena  vein;  its  course  in  the 
thigh  commences  just  behind  the  posterior  part  of  the 
internal  condyle,  and  passing  obliquely  upwards  perfo- 
rates the  fascia  lata  at  the  saphenous  opening,  being 
there  invested  by  the  cribriform  fascia,  and  terminates 
in  the  common  femoral  vein.  It  is  very  subject  to  a 
varicose  condition,  and  may  become  enormously  dilated. 

The  course  of  the  lymphatics  is  pretty  much  that  of 
the  vein,  and  they  terminate  in  those  lymphatic  ganglia, 
situate  in  Scarpa's  space,  which  lie  in  the  axis  of  the 
thigh. 

The  superficial  nerves  are  derived  from  the  anterior 


MIDDLE    FEMORAL    REGION.  249 

crural,  ilio-inguinal  and  crural  branch  of  genito-crural 
nerves ;  and  posteriorly  the  integument  is  supplied  by  the 
lesser  sciatic. 

Beneath  the  subcutaneous  cellular  tissue  is  the  fascia 
lata,  forming  an  envelope  for  the  muscles,  the  arrange- 
ment of  which  in  the  upper  portion  of  the  thigh  has  been 
described  with  those  regions.  A  very  strong  dense  pro- 
cess, into  which  the  tensor  fasciae  is  inserted,  is  attached 
to  the  head  of  the  fibula  and  to  the  outer  surface  of  the 
knee-joint.  This  fascia  invests  the  muscles  so  closely 
and  firmly  that  its  rupture  allows  of  the  bulging  of  the 
fibres  of  the  subjacent  muscles  to  an  extent  which  would 
hardly  be  credited  unless  seen.  Processes  of  this  envelop- 
ing fascia  form  special  sheaths  for  the  muscles. 

The  fascia  lata  is  attached  deeply,  on  the  outer  side, 
to  the  line  leading  from  the  trochanter  major  to  the 
linea  aspera,  and  extends  downwards  to  the  tip  of  the 
external  condyle,  and  on  the  inner  side  to  the  line  lead- 
ing from  the  lesser  trochanter  to  the  linea  aspera,  and 
downwards  to  the  tip  of  the  internal  condyle.  Thus  it 
will  be  seen,  that  the  intermuscular  septa  thus  formed, 
divide  the  thigh  into  two  distinct  compartments,  an  an- 
terior and  a  posterior. 

An  intercommunication,  however,  does  take  place, 
owing  to  the  passage  of  the  femoral  vessels  through  the 
adductor  opening,  of  the  perforating  branches  superiorly, 
and  of  the  upper  articulating  branches  of  the  popliteal 
vessels  inferiorly. 

The  anterior  of  these  compartments,  beneath  the  fascia 
lata,  contains  externally  and  above  the  tensor  fasciae, 
which  is  inserted  obliquely  into  its  substance ;  the  sar- 
torius,  in  its  own  sheath,  which  passes  obliquely  from 
the  anterior  superior  iliac  spine,  and  wraps  round  the 


250  SURGICAL    ANATOMY    OF    THE 

thigh,  being  throughout  its  extent  from  the  apex  of 
Scarpa's  space,  a  satellite  to  the  femoral  artery  and  vein ; 
between  these  muscles  lie  the  rectus  femoris,  becoming 
associated  in  the  inferior  third  with  the  underlying  mus- 
cles, the  vasti  and  crureus,  which  envelop  the  femur 
from  the  great  trochanter  to  the  patella.  Beneath  the 
crureus  is  the  subcrureus,  inserted  into  the  synovial  mem- 
brane of  the  knee-joint,  which  extends  upwards  beneath 
the  extensors  and  the  periosteum  of  the  femur  for  about 
three  to  four  inches.  Its  office  is  to  draw  up  the  mem- 
brane, so  that  in  extreme  and  sudden  extension  of  the 
articulation  it  may  not  be  pinched  between  the  femur 
and  the  patella. 

The  Femoral  Artery  in  the  middle  of  the  Thigh — Hun- 
ter's Canal. — Commencing  at  the  apex  of  Scarpa's  space, 
the  artery  describes  an  oblique  course,  lying  covered  over 
by  the  sartorius  in  its  sheath,  immediately  beneath  which 
is  a  strong  fibrous  aponeurosis,  derived  from  the  vastus 
interims  externally,  and  the  tendons  of  insertion  of  the 
adductor  longus  and  magnus  internally.  This  aponeu- 
rosis is  very  thin  in  the  upper  part  of  the  middle  femoral 
region,  but  becomes  very  dense  lower  down,  terminating 
in  a  sharp  margin,  beneath  which  the  internal  saphena 
nerve  leaves  the  vessel.  External  to  the  femoral  vessels, 
is  the  vastus  internus  muscle ;  and  internal  to  them  are 
the  tendons  of  the  adductor  longus  and  magnus,  and  be- 
hind them  are  the  conjoined  tendons  of  the  vastus  inter- 
nus and  adductors ;  and  in  the  middle  third,  the  fibres 
of  the  vastus  internus  alone  separate  the  vessels  from  the 
femur.  In  this  canal,  which  is  triangular  in  section, 
with  its  apex  at  the  femur,  lie  the  femoral  artery  and 
vein  posterior  to  and  very  intimately  united  with  it ;  the 
long  saphena  nerve  enters  it  with  the  vessels,  above  and 


MIDDLE    FEMORAL    REGION. 


251 


externally,  and  after  crossing  the  artery,  leaves  the  canal 
at  the  point  above  indicated,  and  is  distributed  to  the 
skin  of  the  knee  and  inner  side  of  the  leg.  The  anas- 


ViG.  42. 


21    22. 


Section  of  the  right  thigh  at  the  apex  of  Scarpa's  triangle.  1.  Profunda  ves- 
sels. 2.  Adductor  longus.  3.  Femoral  vessels.  4.  Superficial  obturator  nerve. 
5.  Sartorius.  6.  Gracilis.  7.  External  cutaneous  nerve.  8.  Pectineus.  9.  Rec- 
tus  femoris.  10.  Adductor  brevis.  11.  Anterior  crural  nerve.  12.  Deep  obtura- 
tor nerve.  13.  External  circumflex  vessels.  14.  Adductor  magnus.  15.  Tensor 
fasciae  femoris.  16.  Semi-membrauosus.  17.  Vastus  internus  and  crureus.  18. 
Semi-tendinosus.  19.  Vastus  externus.  20.  Small  sciatic  nerve.  21.  Biceps 
femoris.  22.  Great  sciatic  nerve.  (HKATII.) 


tomotica  magna  artery  is  generally  given  off  from  the 
trunk,  just  before  the  vessel  becomes  popliteal,  that  is, 
before  it  passes  through  the  adductor  opening. 

The  superficial  femoral  is  easily  compressed  against  the 
femur,  at  the  middle  of  the  inner  third  of  the  thigh. 

7  O 

Ligature  of  the  Femoral  Artery  in  Hunter's  Canal. — 
This  operation  is  rarely  performed  nowadays,  unless  it 
be  for  a  wound  in  this  portion  of  its  course,  the  ligature 


252  SUEGICAL    ANATOMY    OF    THE 

of  the  femoral  for  popliteal  aneurism  being  applied  in 
Scarpa's  space. 

An  incision  is  to  be  made  in  the  course  of  the  vessel 
about  three  inches  in  length,  through  the  integument 
and  fascia  lata,  until  the  oblique  fibres  of  the  sartorius 
are  recognized.  Its  edge  reached,  the  muscle  is  to  be 
pulled  upwards,  when  the  aponeurotic  fibres  bridging 
over  the  vessels  will  be  seen.  These  are  to  be  pinched 
up  and  divided  on  a  director,  when  the  artery  (and  per- 
haps the  internal  saphena  nerve)  will  be  seen  with  its 
vein,  which  is  either  behind  it,  or  a  little  to  its  outer 
side,  and  closely  united  to  it  by  a  dense  fibrous  invest- 
ment. Occasionally  the  anastomotica  magna  is  very 
large  and  superficial,  and  may  be  mistaken  for  the  main 
trunk. 

The  posterior  compartment  of  the  thigh,  as  formed  by 
the  fascia  lata,  contains — the  hamstring  muscles,  the 
great  sciatic  nerve,  a  great  deal  of  fat  and  cellular  tissue, 
and  the  terminations  of  the  perforating  branches  of  the 
deep  femoral  vessels;  it  presents  but  few  points  of  sur- 
gical interest. 

If  amputation  through  the  middle  third  were  performed 
by  means  of  antero-posterior  flaps  (the  operation  to  be 
preferred),  the  anterior  would  contain  the  integuments 
of  the  thigh,  with  the  cutaneous  nerves  and  internal 
saphena  vein,  the  rectus,  sartorius,  adductor  longus, 
brevis,  and  gracilis  muscles,  obturator  nerve,  femoral 
vessels,  and  branches  of  anterior  crural  nerve,  a  portion 
of  the  vastus  externus,  internus,  and  adductor  magnus 
muscles.  The  posterior,  portion  of  vastus  externus  and 
internus,  adductor  longus,  brevis,  and  magnus  muscles, 
deep  femoral  and  perforating  vessels,  the  hamstring  mus- 
cles, great  sciatic  nerve,  lesser  sciatic  nerve,  and  integu- 


REGION    OF    THE    KNEE.  253 

mcnts  of  back  of  thigh.  If  the  amputation  be  performed 
near  the  knee,  the  muscles  are  liable  to  great  contraction, 
since  they  take  their  fixed  points  at  the  pelvis  superiorly. 
Hence  the  flaps,  which  should  be  lateral,  external  and 
internal,  must  be  cut  as  long  as  possible.  The  strong 
fibrous  sheaths  of  the  muscles  favor  the  bagging  of  pus 
in  amputations  through  the  thigh. 

In  cases  of  wounds  of  the  thigh,  in  which  either  the 
superficial  or  deep  femoral  is  implicated,  an  approxima- 
tive diagnosis  of  the  site  of  the  escape  of  blood  may  be 
made  by  examining  the  posterior  tibial  artery  at  the 
inner  ankle.  If  it  pulsates,  in  all  probability  the  super- 
ficial femoral  is  intact,  and  the  profunda  wounded ;  on 
the  other  hand,  if  the  superficial  femoral  be  the  seat  of 
injury,  the  blood,  instead  of  continuing  its  course  along 
it,  and  causing  pulsation  in  the  posterior  tibial,  is  es- 
caping into  the  surrounding  tissues,  and  forming  a  false 
aneurism.  In  enlarging  the  wound  to  find  the  bleeding 
point,  it  must  be  remembered  that  the  profunda  is  ex- 
ternal to  the  superficial  femoral,  and  that  the  veins  of 
either  will  be  most  likely  involved. 

In  fractures  of  the  shaft  of  the  femur,  the  lower  frag- 
ment is  always  drawn  to  the  inner  side  of  the  upper  one, 
and  rotated  outwards,  although  in  some  instances  in- 
wards :  in  the  former  case,  owing  to  the  contraction  of 
the  psoas  and  iliactis,  and  external  rotators ;  in  the  latter, 
to  the  internal  rotators. 

SURGICAL  ANATOMY  OF  THE  REGION  OF  THE 
KNEE. 

This  region  is  limited  below  by  a  line  drawn  round 
the  leg  just  below  the  internal  tuberosity  of  the  tibia  ;  it 
will  be  thus  seen  that  the  popliteal  space,  which  partly 

22 


254  SURGICAL    ANATOMY    OF    THE 

belongs  to  the  lower  third  of  the  thigh,  the  knee-joint, 
and  the  upper  portion  of  the  leg,  is  conveniently  associa- 
ted with  the  surgical  anatomy  of  the  knee. 

Surface  Markings. — If  the  leg  be  extended  on  the  thigh, 
from  above  downwards,  in  front  is  the  tendon  of  the 
quadriceps  extensor,  in  which  lies  subcutaneously  the 
patella,  from  the  lower  border  of  which  descends  the 
ligamentum  patellae  passing  to  its  insertion  in  the  tuber- 
cle of  the  tibia;  on  either  side  of  the  quadriceps  extensor 
tendon  is  a  deep  furrow,  between  it  and  the  vasti  muscles. 
In  cases  of  synovitis,  this  furrow  is  obliterated,  owing  to 
the  collection  of  fluid  causing  the  synovia!  membrane  to 
bulge  beneath  the  tendon.  If  the  leg  be  flexed^  the 
condyles  of  the  femur,  and  the  interspace  between  them, 
are  very  evident,  and  the  patella  fills  up  the  interval 
between  the  femur  and  the  tibia,  tuberosities  of  which  are 
readily  seen.  In  front  of  the  patella  and  ligameutum 
patella?  the  integument  is  slightly  raised  at  a  spot  corre- 
sponding with  the  bursa  patellae. 

Posteriorly ,  during  complete  extension  the  surface  of 
the  popliteal  space  is  convex,  and  the  positions  of  the 
muscles  which  bound  it,  although  evident,  are  not  so  pro- 
nounced as  when  flexion  commences ;  the  most  salient 
tendon  is  that  of  the  semi-tendinosus.  The  position  of 
the  external  and  internal  popliteal  nerves  lying  in  the 
middle  of  the  space  is  easily  seen  during  extension,  as, 
being  put  on  the  stretch,  they  lie  immediately  beneath 
the  integument,  and  resemble  tendons.  Externally,  the 
knee  presents  a  depression,  formed  by  the  obliquity  of 
the  axes  of  the  femur  and  tibia,  the  deepest  part  of 
which  corresponds  with  the  position  of  the  outer  interar- 
ticular  fibro-cartilage.  Above  this  is  the  external  con- 
dyle  of  the  femur,  below  the  external  tuberosity  of  the 


REGION    OF    THE    KNEE.  255 

tibia,  whilst  posterior  to  it  is  the  head  of  the  fibula  and 
tendon  of  biceps;  just  behind  the  tendon  of  the  biceps, 
and  below  the  head  of  the  fibula,  can  be  felt  the  external 
popliteal  nerve.  Internally  can  be  felt  the  internal  con- 
dyle  and  internal  tuberosity  of  the  tibia,  separated  by  the 
position  of  the  interarticular  fibro-cartilage.  The  inter- 
nal saphena  vein  is  seen  beneath  the  integument,  just 
behind  the  inner  condyle. 

The  skin  of  the  region  is  very  thick  and  dense,  and 
the  subcutaneous  cellular  tissue  contains,  the  internal 
saphena  vein  and  nerve ;  on  the  inner  side  and  in  front 
of  the  patellae,  the  bursa  patellae,  effusion  into  which 
constitutes  the  affection  known  as  "  housemaid's  knee." 
In  the  early  stage,  inflammation  of  this  bursa  is  to  be 
distinguished  from  synovitis  by  the  fact  of  the  patella 
being  hidden  by  the  distended  sac,  whilst  the  cavities  on 
either  side  of  it  remain ;  the  fibrous  tissue,  however, 
along  the  edge  of  the  patella  being  thin,  pus  may  find 
its  way  into  the  synovial  cavity.  The  aponeurosis  is  a 
continuation  of  the  fascia  lata,  and  is  attached^  firmly  to 
the  tubercle  of  the  tibia  and  its  tuberosities,  to  the  head 
of  the  fibula,  afterwards  blending  with  the  fascia  lata  of 
the  leg.  Beneath  this  aponeurosis  lie  the  muscles, 
which  have  the  following  relations  : 

Internally  are  the  sartorius,  gracilis,  and  semi-tendi- 
nosus,  the  tendons  of  which  muscles'  strengthen  the  apo- 
neurosis by  their  fibrous  expansions,  and  are  separated 
from  the  tibia  by  a  large  bursa,  and  the  semi-membrano- 
sus.  Externally,  the  tendon  of  the  biceps,  anteriorly,,  is 
the  tendon  of  the  quadriceps  extensor  and  the  ligamen- 
tum  patellae,  between  which  and  the  tibia  is  a  bursa 
(bursa  of  Cloquet).  The  articular  branches  of  the  popli- 


256  SURGICAL    ANATOMY    OF    THE 

teal,  anterior  tibial  recurrent,  and  anastomotica  magna 
ramify  on  the  capsule. 

The  popliteal  space  forms  the  posterior  aspect  of  the 
knee. 

Dissection. — The  skin  is  thin,  and  has  beneath  it  a 
considerable  amount  of  fat.  It  contains  a  number  of 
lymphatic  glands,  which  are  liable  to  suppuration,  or  to 
enlargement  after  injuries  to  the  foot  or  leg;  they  are 
divided  into  two  series — a  superficial,  which  accompany 
the  saphena  veins,  and  a  deeper,  which  lie  with  the  popli- 
teal vessels ;  suppuration  in  these  glands  has  been  mis- 
taken for  aneurism. 

The  external  saphena  vein  lies  in  this  tissue  before  it 
perforates  the  popliteal  aponeurosis  to  join  the  popliteal 
vein ;  here  also  are  some  branches  of  the  small  sciatic 
nerve.  The  popliteal  aponeurosis  continuous  with  the 
fascia  lata  above  and  fascia  of  leg  below,  is  attached  to  the 
bony  prominences  and  ligaments,  and  forms  sheaths  for 
the  muscles  and  vessels  of  the  space  ;  strong  transverse 
bands  stretch  across  the  space,  and  by  connecting  the 
tendons  of  the  hamstrings,  the  fascia  is  rendered  very 
tense.  This  fascia,  from  its  strength  and  power  of  resist- 
ance, complicates  the  diagnosis  of  tumors  in  the  space. 

The  boundaries  of  the  popliteal  space  are,  externally,  the 
biceps  above,  the  external  head  of  gastrocnemius  and 
origin  of  plantaris  below.  Internally,  the  tendons  of 
the  semi-tendinosus,  semi-membranosus,  gracilis  and 
sartorius  above,  and  the  inner  head  of  the  gastrocnemius 
below. 

These  muscles  are  very  subject  to  contraction  after 
strumous  disease  of  the  knee-joint,  and  to  cause  subse- 
quent dislocation  of  the  leg  upon  the  thigh,  in  cases 
where  the  disease  has  not  been  combated  by  treatment. 


REGION    OF    THE    KNEE.  257 

Connected  with  the  tendons  of  these  muscles  are  bursal 
sacs,  which  are  of  surgical  importance,  as  if  enlarged  or 
inflamed  they  may  oifer  some  difficulties  in  diagnosis. 
Thus,  one  exists  between  the  inner  head  of  the  gastroc- 
nemius  and  the  condyle  of  the  femur,  and  often  commu- 
nicates with  the  joint,  another  exists  between  the  tendon 
of  the  semi-membranosus  and  the  tibia ;  the  bursa  be- 
neath the  outer  head  of  the  gastrocnemius  is  generally  a 
prolongation  of  the  synovial  membrane  of  the  joint,  and 
between  the  popliteal  tendon  and  the  posterior  and  exter- 
nal lateral  ligaments  there  often  are  found  separate  bursse. 
The  muscles  above  mentioned  inclose  a  lozenge-shaped 
space,  containing  a  large  quantity  of  fat  and  cellular 
tissue,  in  which  lie  the  popliteal  vessels,  nerves,  and 
some  lymphatics ;  as  this  fat  and  cellular  tissue  is  con- 
tinuous with  that  surrounding  the  muscles  of  the  back 
of  the  thigh  and  calf,  any  collections  of  pus  in  the  space 
are  liable  to  extend  up  the  limb  or  downwards  amongst 
the  muscles  of  the  back  of  the  leg.  Most  superficial  in 
the  ^space,  on  the  outer  side,  is  the  external  popliteal 
nerve,  which  lies  on  the  inner  margin  of  the  biceps  ten- 
don, and  must  be  carefully  avoided  in  tenotomy ;  the 
external  saphena  vein  lies  to  its  inner  side,  after  having 
perforated  the  popliteal  aponeurosis.  More  internal 
still  is  the  internal  politeal  nerve,  which  is  the  continu- 
ation directly  downwards  of  the  sciatic  nerve,  in  the  in- 
ferior portion  of  the  space ;  this  nerve  gives  off  a  leash 
of  branches  which  supply  the  muscles  of  the  calf,  and  a 
filament,  the  communicans  poplitei,  which  joins  a  corre- 
sponding one  from  the  external  popliteal,  the  communi- 
cans peronei,  forming  a  loop  which  generally  lies  in  the 
sulcus  between  the  two  heads  of  the  gastrocnemius  (ex- 
ternal saphena).  The  sheath  of  the  popliteal  vessels  is 


258 


SURGICAL    ANATOMY    OF    THE 


FIG.  43. 


very  dense,  and  incloses  the  popliteal  artery  and  vein, 
which  latter  lies  internal  to  the  internal  popliteal  nerve, 
and  superficial  to  the  artery. 

The  Popliteal  Artery.— The 
course  of  this  vessel  in  the 
space  is  indicated  by  a  line 
which,  commencing  at  the  cen- 
tre of  Pou  part's  ligament,  and 
wrapping  round  the  thigh, 
would  fall  immediately  be- 
tween the  two  condyles  of  the 
femur  behind  ;  commencing  at 
the  opening  in  the  adductor 
magnus,  it  extends  to  the 
lower  border  of  the  popliteus 
muscle;  it  lies  close  to  the 
surface  of  the  bone,  and  gives 
off  its  articular  branches  near- 
ly at  right  angles  to  its  course. 
Between  the  artery  and  the 
vein  is  the  articular  branch 
of  the  obturator  nerve,  which 
supplies  the  knee-joint.  The 
artery  and  vein  are  in  such 
intimate  relation  that  it  would 
be  almost  impossible  for  a 

Deep  dissection  of  the  popliteal  space.  1.  Adductor  magnus.  2.  Vastus  exter- 
nus.  3.  Popliteal  vein.  4.  Great  sciatic  nerve.  5.  Popliteal  artery.  6.  Short 
head  of  biceps.  7.  Internal  popliteal  nerve.  8.  External  popliteal  nerve.  9. 
Vastus  interims.  10.  Long  head  of  biceps  (cut).  11.  Superior  internal  articular 
artery.  12.  Outer  head  of  gastrocneniius.  13.  Tendon  of  serai-membranosus. 
14.  Communicans  peronei  nerve.  15.  Inner  head  of  gastrocneniius.  16.  Soleus. 
17.  Inferior  internal  articular  artery.  18.  Gastrocnemius.  19.  Popliteus.  20. 
External  saphenous  vein  and  nerve.  21.  Tendon  of  plantaris.  (HEATH.) 


REGION    OF    THE    KNEE.  259 

punctured  wound  of  the  ham  which  entered  the  artery, 
not  to  involve  the  vein  also. 

Relations  of  the  Popliteal  Artery. — In  front,  just  be- 
neath the  tendinous  arch  in  the  adductor  magnus  tendon, 
is  the  inner  side  of  the  femur ;  having  wound  round  that 
bone,  it  has  that  portion  of  it  between  the  bifurcation 
of  the  linea  aspera  in  front  of  it,  in  the  middle  of  its 
course  the  posterior  ligament  of  the  articulation,  and 
below,  the  popliteal  fascia.  Behind,  is  the  popliteal  vein, 
internal  popliteal  nerve,  aponeurosis;  externally,  biceps; 
internally,  semi-membranosus. 

The  branches  of  the  vessel  are  the  muscular,  the  su- 
perior and  inferior  external  and  internal  articular,  and 
the  a/ygos,  which  pierces  the  posterior  ligament.  These 
vessels  maintain  a  very  free  anastomosis  round  the  joint 
amongst  themselves,  the  anastomotica  magna,  anterior 
tibial  recurrent,  and  muscular  branches. 

Ligature  of  the  popliteal,  as  a  definite  operation,  is 
never  practiced  in  modern  surgery,  for  reasons  which 
will  be  found  discussed  in  works  on  aneurism. 

The  diagnosis  of  tumors  in  the  popliteal  space  may, 
in  most  instances,  be  reduced  to  anatomical  principles, 
thus :  such  tumors  must  be  either  aneurism  (circum- 
scribed or  diffused),  abscess,  enlarged  glands,  cysts,  or 
growths,  &c.  In  the  event  of  an  aneurism,  compression 
of  the  femoral  would  empty  its  sac,  and  the  sound  com- 
municated to  the  ear  by  a  stethoscope  would  be  of  a 
prolonged,  blowing  nature.  Cysts,  such  as  those  al- 
luded to  as  connected  with  the  tendons,  even  if  they 
have  a  communicated  pulsation  from  being  so  closely 
packed  together  with  the  vessel,  could  be  dragged  away 
from  it,  and  then  these  seeming  pulsations  would  cease. 
In  the  diagnosis  between  an  abscess  and  an  aneurism  the 


260  SURGICAL    ANATOMY    OF 

sac  of  which  had  suppurated,  or  between  an  abscess  and 
ruptured  popliteal  artery,  forming  a  diffuse  aneurism, 
difficulty  might  be  expected ;  but  here  the  condition  of 
the  pulse  below  will  generally  determine  the  case. 

SURGICAL  ANATOMY  OF  THE  KNEE-JOINT. 

The  articulations  of  the  knee-joint  are  three  in  num- 
ber— viz.,  between  the  femur  and  the  patella,  between 
the  femur  and  the  tibia,  and  between  the  tibia  and  the 
head  of  the  fibula.  The  structure  of  the  bones  entering 
into  the  formation  of  the  joint  is  the  same  in  each  in- 
stance,— cancellated  tissue,  inclosed  in  a  layer  of  compact 
tissue.  The  articular  extremities  of  the  bones  are  well 
supplied  with  bloodvessels,  these  enter  the  patella  on  its 
anterior,  and  the  femur  on  its  posterior  surface. 

The  articular  surface  of  the  patella  is  divided  verti- 
cally by  a  crest  into  two  facets,  the  rounder  of  which 
corresponds  with  the  outer,  and  .the  longer  and  flatter 
with  the  inner  articular  portion  of  the  trochlea. 

The  lower  articular  end  of  the  femur  is  convex  in 
front  and  concave  posteriorly,  and  the  internal  condyle 
is  lower  than,  and  a  little  posterior  to,  the  external,  pre- 
senting on  its  inner  side  the  inner  tuberosity  for  the  at- 
tachment of  the  internal  lateral  ligament,  and  a  well- 
marked  tubercle,  very  plainly  felt  beneath  the  integu- 
ment, for  the  attachment  of  the  tendon  of  the  adductor 
magnus.  The  tuberosity  of  the  outer  condyle  is  less 
prominent  than  that  of  the  inner,  and  gives  attachment 
to  the  external  lateral  ligament.  The  articular  surface 
extends  higher  on  the  outer  side  than  on  the  inner,  and 
is  moreover  in  advance  of  it  and  broader.  During  com- 
plete flexion  only,  the  patella  occupies  the  centre  of  the 


THE    KNEE-JOINT.  261 

trochlea,  but  in  extension  it  overlaps  the  outer  portion 
of  the  articular  surface,  and  rises,  if  the  extension  be 
extreme,  half  its  diameter  above  it. 

The  femur  and  the  patella  are  united  by  the  fibrous 
capsule  and  by  the  tendon  of  the  quadriceps  extensor. 
The  great  power  exerted  by  the  action  of  the  quadriceps 
on  the  patella  above,  and  its  strong  attachment  to  the 
tibia  by  the  ligamentnm  patellae  below,  explain  how  this 
bone  may  be  fractured  transversely  by  muscular  action. 

Dislocations  of  the  Patella. — This  bone  is  most  fre- 
quently dislocated  outwards.  The  bone  lying  above  and 
external  to  the  external  articular  surface  of  the  trochlea, 
the  outward  traction  of  the  extensor  muscles  favors  this 
form  of  displacement.  Dislocation  inwards  is  very  rare. 
Dislocation  with  the  bone  lying  vertically  either  on  the 
outer  or  the  inner  condyle  is  also  very  rare.1 

The  Articulation  between  the  Femur  and  the  Tibia. — 
The  inner  articular  surface  of  the  condyle  of  the  femur 
is  less  prominent  anteriorly  than  the  external,  but  is  set 
lower  and  extends  a  little  further  backwards,  and  is  more 
oblique  laterally.  These  surfaces  are  separated  posteri- 
orly by  the  intercondyloid  notch.  The  head  of  the  tibia 
presents  two  concave  articular  surfaces,  the  external  of 
which  is  the  rounder,  separated  by  the  spine,  in  front 
and  behind  which  is  a  rough  depression  to  which  are 
attached  the  crucial  ligaments. 

The  femur  and  tibia  are  united  by  the  capsular  liga- 
ment, posteriorly  by  the  posterior  ligament,  which  is  a 
prolongation  upwards  of  the  tendon  of  the  semi-mem- 
branosus,  an  internal  and  external  lateral  ligament,  two 

1  Vide  case  in  practice  of  author,  British  Medical  Journal,  De- 
cember, 1872. 


262  SURGICAL    ANATOMY    OF 

crucial,  the  anterior  or  external  and  the  internal  or  pos- 
terior, and  the  two  interarticular  semilunar  fibro-carti- 
lages. 

The  synovial  membrane  of  the  knee-joint  ascends  up- 
wards beneath  the  extensor  muscles,  as  a  pouch,  for 
about  three  inches,  and  is  reflected  from  the  articular 
surfaces  of  the  femur,  to  the  crucial  ligaments  and  ar- 


FIG.  44. 


Knee-joint  opened  vertically.  1.  Tendon  of  quadriceps  extensor.  2.  Sub- 
crureus.  3.  Cut  edge  of  synovial  membrane.  4.  Patella  divided  vertically. 
5.  Ligamentum  mucosum.  6.  Posterior  crucial  ligament.  7.  Anterior  ditto. 
8.  Adipose  tissue.  9.  Bursa  beneatb  ligameutum  patellae.  10.  Ligamentum 
patellae. 

ticular  surface  of  the  tibia,  enveloping  the  semilunar 
cartilages,  and  at  the  back  of  the  external,  forms  a  pouch 
between  its  surface  and  that  portion  of  the  tendon  of  the 
popliteus  which  is  within  the  capsule;  it  then  lines  the 
capsular  ligament. 


THE    KNEE-JOINT.  263 

The  lower  epiphysis  of  the  femur  presents  an  ossified 
nodule  at  the  ninth  month  of  foetal  life,  a  fact  of  con- 
siderable value  medico-legally  in  determining  the  age 
of  the  child.  The  entire  epiphysis,  however,  does  not 
unite  with  the  shaft  until  the  twentieth  year ;  the  upper 
epiphysis  of  the  tibia  at  the  twenty -fifth  year. 

Movements  of  the  Knee-joint. — Flexion  is  performed  by 
the  biceps,  semi-tendinosus,  membranosus,  popliteus,  and 
accessorily  by  the  gastrocnemius.  Extension  by  the 
quadriceps  extensor,  and  tensor  vaginae  femoris.  When 
the  leg  is  semiflexed,  the  joint  can  be  internally  rotated 
by  the  sartorius,  semi-tendinosus,  and  gracilis;  externally 
by  the  biceps. 

Relations  of  the  Knee-joint,  externally. — The  tendon  of 
the  biceps  and  the  strong  process  of  fascia  lata  into  which 
is  inserted  the  tensor  fascia? ;  internally  and  a  little  pos- 
teriorly, the  sartorius,  semi-tendinosus,  gracilis,  and  semi- 
mem  branosus  ;  all  these  tendons  are  inclosed  in  bursal 
sheaths ;  posteriorly,  the  tendon  of  the  popliteus  and  the 
tendon  of  the  muscles  forming  the  popliteal  space,  with 
the  contents  of  the  space  itself. 

Fracture  of  the  patella  when  due  to  muscular  action  is 
always  transverse,  and  the  separation  of  the  fragments 
to  the  upward  traction  of  the  quadriceps  extensor  acting 
on  the  upper  one,  whilst  the  lower  is  retained  in  position 
by  the  ligamentum  patellae.  With  a  view  to  treatment, 
the  tension  should  be  relaxed,  by  extending  the  leg  on 
the  femur,  and  by  slightly  flexing  the  thigh  on  the  pel- 
vis so  as  to  relax  the  rectus  muscle.  Non-union  is  some- 
times owing  to  the  bulging  of  the  synovial  membrane 
between  the  opposed  fragments. 

The  articulation  between  the  upper  extremities  of  the 
tibia  and  fibula  is  an  arthrodial  joint,  consisting  of  two 


264  SURGICAL    ANATOMY    OF 

opposed  articular  spaces,  united  by  two  ligaments,  an 
anterior  and  posterior,  with  a  synovial  membrane  be- 
tween, occasionally  communicating  with  that  of  the  knee- 
joint;  a  circumstance  explaining  the  implication  of  the 


Fio.  45. 


Horizontal  section  of  knee-joint.  1.  Patella.  1'.  Synovial  membrane.  2. 
Capsule.  3.  Femur.  4.  Crucial  ligaments.  5.  Biceps.  6.  Outer-  head  of  gas- 
trocnemius.  7.  Popliteal  artery.  8.  External  popliteal  nerve.  9.  Popliteal 
vein.  10.  Internal  popliteal  nerve.  11.  External  saphena  vein.  12.  Semi-ten- 
dinosus.  13.  Semi-membranosus.  14.  Gracilis.  15.  Sartorius.  16.  Inner  head 
of  gastrocneinius. 

synovial  membrane  of  the  head  of  the  fibula  becoming 
involved  in  effusions  into  the  knee-joint. 

The  operations  which  concern  the  knee-joint  are  ex- 
cision and  amputation  through  it. 

Excision  of  the  Knee-joint. — The  articular  surfaces 
which  require  removal  may  be  exposed  in  several  ways, 
the  simplest  being  by  a  semilunar  incision,  extending 
from  the  inner  side  of  the  inner  condyle  to  the  outer  side 
of  the  external,  the  convexity  of  the  incision  lying  mid- 
way between  the  lower  border  of  the  patella  and  the 
tubercle  of  the  tibia ;  the  joint  is  thus  opened  at  once. 
The  articular  extremities  of  the  femur  and  tibia,  or  pa- 


THE    LEG.  265 

tella,  are  to  be  removed  according  to  circumstances ;  but 
in  the  instance  of  performing  the  operation  on  children, 
it  is  of  great  importance  to  avoid  removing  the  entire 
epiphyses,  as  there  would  then  be  no  further  growth  in 
the  limb. 

Structures  Divided  in  Excision  of  the  Knee-joint. — In- 
tegument and  aponeurosis,  patellar  plexus  of  nerves,  bursa 
patellae,  ligamentum  patellae,  anterior  part  of  capsular 
ligament,  synovial  membrane,  crucial  ligaments,  lateral 
ligaments,  articular  vessels,  and  articular  extremities  of 
femur  and  tibia.  The  popliteal  vessels  are  separated 
from  the  opened  joint  by  the  posterior  ligament  and 
poplitens  muscle. 

SURGICAL  ANATOMY  OF  THE  LEG. 

The  surgical  region  of  the  leg  commences  just  below 
the  knee,  and  extends  to  an  imaginary  line  drawn  round 
the  lower  part  of  the  limb,  just  above  the  malleoli. 

Surface  Markings. — Anteriorly  is  the  crest  of  the  tibia, 
internal  to  which  is  the  flat  plane  surface  of  the  shaft  of 
the  bone,  which  being  subcutaneous  throughout  permits 
of  ready  examination,  and  external  to  it  is  the  mass  of 
the  tibialis  anticus,  and  extensors  of  the  toes.  Externally 
are  the  peronei,  separated  by  a  well-marked  groove  cor- 
responding to  the  interspace  between  them  and  the  ex- 
ternal edge  of  the  soleus.  Posteriorly  is  the  swell  of  the 
calf,  due  to  the  gastrocenemius  and  soleus,  the  division 
between  the  two  heads  of  the  former  being  marked  by  a 
furrow  continuous  with  the  lower  portion  of  the  popli- 
teal space.  As  the  muscular  fibres  cease,  the  tendo- 
Achillis  becomes  more  evident. 

The  leg  can  be  readily  divided  into  two  regions,  an 


266    -  SURGICAL    ANATOMY    OP 

anterior  and  a  posterior,  limited  by  the  inner  border  of 
the  tibia  internally  and  the  outer  border  of  the  fibula 
externally. 

Anterior  Region. — The  skin  is  freely  movable  over 
the  subjacent  tissues,  and  in  the  subcutaneous  cellular 
tissue  and  fat  lie  the  internal  saphena  vein,  which  cross- 
ing the  inner  malleolus,  passes  upwards  toward  the  pos- 
terior border  of  the  inner  condyle  of  the  femur,  and  is 
accompanied  by  the  internal  saphena  nerve.  The  aponeu- 
rosis  is  the  continuation  downwards  of  the  fascia  lata, 
strengthened  superiorly  and  internally  by  the  expansion 
of  the  sartorius  tendon,  and  thickened  inferiorly  where 
it  forms  the  annular  ligament  of  the  ankle.  It  is  ad- 
herent to  the  anterior  surface  of  the  tibia  and  external 
border  of  the  fibula,  and  sends  septa  between  and  gives 
attachment  to  the  anterior  muscles  of  the  limb ;  it  is  per- 
forated in  several  places  for  the  passage  of  the  cutaneous 
nerves.  Inclosed  in  the  space  between  the  aponeurosis 
superiorly  and  the  tibia,  fibula,  and  interosseous  mem- 
brane posteriorly,  lie  in  the  first  layer  of  muscles,  the 
tibialis  anticus  and  the  extensor  com  munis  digitorum, 
united  superiorly  by  an  intermuscular  septum  lower 
down.  They  separate  and  inclose  the  origin  of  the  ex- 
tensor proprius  pollicis,  external  to  and  below  which  is 
the  peroneus  tertius.  The  space  between  these  muscles 
and  the  interosseous  membrane  is  occupied  by  the  an- 
terior tibial  vessels  and  nerve ;  the  nerve  pursuing  the 
same  course  as  the  artery  lies  at  first  external  to,  then 
upon,  and  then  again  outside  the  vessels. 

External  Region. — The  aponeurosis  forms  an  invest- 
ment for  the  peronei  muscles ;  the  compartment  corre- 
sponding to  the  external  surface  of  the  fibula.  To  the 
upper  and  middle  thirds  of  this  surface  the  peroneus 


THE    LEG.  •»    267 

longus  is  attached ;  the  upper  fibres  are  pierced  by  the 
external  popliteal  nerve,  which  at  this  point  divides  into 
anterior  tibial  and  musculo-cutaneous;  the  latter  perfo- 
rating the  fascia  about  the  middle  third  of  the  leg. 
Arising  from  the  middle  third  of  the  fibula  the  peroneus 
brevis  is  inclosed  in  the  same  compartment. 

The  Anterior  Tibial  Artery. — The  course  of  this  vessel 
is  indicated  by  a  line  drawn  from  the  inner  side  of  the 
head  of  the  fibula  to  midway  between  the  malleoli.  It 
enters  the  region  at  a  point  below  the  popliteus  muscle, 
and  passes  between  the  upper  portion  of  the  two  heads 
of  origin  of  the  tibialis  posticus,  and  comes  off  from  the 
popliteal  almost  at  a  right  angle.  Its  relations  are,  an- 
teriorly, integument  and  fasciae,  tibialis  anticus  (above), 
extensor  longus  digitorum  and  extensor  proprius  pollicis, 
and  the  anterior  tibial  nerve ;  internally,  tibialis  anticus, 
extensor  proprius  pollicis  (which  crosses  it  at  the  instep) ; 
externally,  the  anterior  tibial  nerve,  extensor  longus  dig- 
itorum, and  extensor  proprius  pollicis ;  posteriorly,  the 
interosseous  membrane,  the  tibia,  and  anterior  ligament 
of  ankle-joint. 

Ligature  of  this  vessel  is  rarely  required,  unless  it  be 
for  a  wound,  which  would  be  enlarged,  and  the  bleeding 
point  sought  for.  To  tie  it,  an  incision  should  be  made 
in  the  upper  third,  in  the  interspace  between  the  tibialis 
anticus  and  the  extensor  communis  digitorum  ;  the  inter- 
muscular  septum  between  them  looked  for,  the  muscular 
fibres  detached  from  it,  and  pulled  on  one  side,  when  the 
vessel,  surrounded  by  venae  comites,  and  having  its  nerve 
to  the  outer  side,  will  be  seen  lying  on  the  interosseous 
membrane. 

In  the  lower  third,  an  incision  should  be  made  along 
the  outer  border  of  the  tibialis  anticus  tendon,  when  the 


268 


SURGICAL    ANATOMY    OF 


vessel  will  be  found  between  it  and  the  tendon  of  the 
extensor  proprius  pollicis,  and  the  nerve  generally  lying 
on  it. 

Posterior  Region. — Beneath  the  integument  and  super- 
ficial fascia  are  the  external  saphena  vein  and  nerve,  and 
some  branches  of  the  musculo-cutaneous  and  internal 

FIG.  46. 


A  section  of  the  right  leg  in  the  upper  third.  1.  Tibialis  posticus.  2.  Tibialis 
anticus.  3.  Flexor  longus  digitorum.  4.  Extensor  longus  digitorum.  5.  Inter- 
nal saphenous  vein.  6.  Anterior  tibial  vessels  and  nerve.  7.  Tendon  of  plan- 
taris.  8.  Peroneus  longus.  9.  Posterior  tibial  vessels  and  nerve.  10.  Flexor 
longus  pollicis.  11.  External  saphenous  vein  and  nerve.  12.  Soleus  with  fibrous 
intersection.  13.  Peroneal  vessels.  14.  Gastrocnemius.  15.  Comraunicans 
peronei  nerve.  (HEATH.) 

saphena  nerves.  The  aponeurotic  sheath,  inclosing  that 
portion  of  the  leg  posteriorly  between  its  attachments  to 
the  tibia  and  fibula,  is  subdivided  by  an  expansion  sepa- 
rating the  superficial  from  the  deep  flexors,  vessels,  and 


THE    LEG.  269 

nerves.  The  most  posterior  contains  the  gastrocnemius 
and  soleus,  uniting  to  form  the  tendo-Achillis,  and  the 
plantaris,  with  a  good  deal  of  fat  and  bursal  tissue. 
The  second,  anterior  to  the  former,  contains  the  flexor 
longus  digitorum  internally,  the  flexor  longus  pollicis 
externally,  and  tibialis  posticus  muscles  between  them, 
closely  united  by  intermuscular  septa.  The  posterior 
tibial  vessels  on  the  tibial  side,  having  the  posterior 
tibial  nerve  external  to  them,  and  the  peroneal  vessels 
on  the  fibula,  lying  at  first  beneath  the  intermuscular 
aponeuroses,  next  between  the  flexor  longus  pollicis  and 
tibialis  posticus,  and  lower  down  the  limb,  between  the 
tibialis  posticus  and  the  fibula. 

The  posterior  tibial  artery  would  rarely  require  liga- 
ture in  its  upper  third,  unless  for  injury,  in  which  case 
the  wound  should  be  enlarged,  and  the  bleeding  point 
secured ;  but  if,  however,  the  vessel  be  divided  by  a 
punctured  wound  from  the  front  of  the  leg,  or  in  the 
case  of  traumatic  aneurism  of  the  vessel,  low  down,  it  is 
necessary  to  place  a  ligature  upon  it  in  this  situation. 

Ligature  of  the  Posterior  Tibial  Artery  in  the  Upper 
Third. — This  vessel  is  reached  most  scientifically  by  an 
incision  made  along  the  posterior  border  of  the  subcuta- 
neous surface  of  the  tibia,  about  four  inches  in  length, 
dividing  the  integument  and  aponeurosis,  taking  care  to 
avoid  the  internal  saphena  vein  and  nerve.  The  inner 
border  of  the  gastrocnemius  is  to  be  drawn  aside ;  when 
the  tibial  head  of  the  soleus  is  reached,  its  fibres  are  to 
be  divided,  until  the  intermuscular  septum  (the  position 
of  which  is  variable)  is  come  upon.  This  is  next  to  be 
cut  through,  and  the  fibres  of  this  muscle  divided  until 
freedom  of  access  is  obtained.  The  cut  edges  of  the 
soleus  are  to  be  separated,  the  smooth  intermuscular  apo- 

23 


270  SURGICAL    ANATOMY    OF 

neurosis  which  separates  the  superficial  from  the  deep 
flexors  is  to  be  divided  on  a  director,  and  the  posterior 
tibial  nerve  drawn  on  one  side ;  the  posterior  tibial  artery, 
surrounded  by  venae  comites,  is  seen  lying  on  the  flexor 
longus  digitorum. 

The  nutritious  artery  is  a  branch  of  considerable  im- 
portance. Directed  upwards  towards  the  knee,  it  enters 
the  shaft  of  the  tibia  in  a  deep  canal  in  the  posterior  as- 
pect, about  four  fingers'  breadth  from  the  knee,  and  may 
give  rise  to  troublesome  hemorrhage  in  amputation  of 
the  leg  at  this  part. 

The  peroneal  artery,  generally  regarded  as  a  branch 
of  the  posterior  tibial,  is  very  often  of  larger  size.  It  is 
very  deep,  and  lying  along  the  fibular  surface  of  the  leg, 
has  the  following  relations  :  In  front,  the  tibialis  posticus 
and  flexor  longus  pollicis ;  externally,  the  fibula ;  and  be- 
hind, the  soleus,  deep  aponeurosis,  and  flexor  longus 
pollicis.  This  vessel  is  occasionally  wounded  in  com- 
pound comminuted  fractures  of  the  fibula. 

In  fractures  of  the  tibia  and  fibula,  which  take  place 
obliquely  from  above,  downwards,  and  forwards,  the 
muscles  of  the  calf  cause  the  lower  fragments  to  be  drawn 
upwards  and  backwards,  and  frequently  the  upper  one 
to  protrude  through  the  integument.  With  a  view  of 
bringing  the  surfaces  into  apposition,  the  knee  should  be 
bent  to  relax  the  opposing  muscles,  and  extension  made 
from  the  knee  and  ankle  (vide  Ankle-joint). 

Fracture  of  the  lower  end  of  the  fibula  is  usually  asso- 
ciated with  fracture  of  the  inner  malleolus  (Pott's  frac- 
ture), or  rupture  of  the  internal  lateral  ligament  of  the 
ankle-joint,  causing  dislocation  of  the  foot  outwards. 
The  eversion  of  the  foot  is  due  to  the  action  of  the  pero- 
neus  longus,  whilst  the  heel  is  drawn  upwards  by  the 


THE    FOOT.  271 

gastrocnemius  and  soleus.  The  reduction  is  effected  by 
flexing  the  leg  at  right  angles  with  the  thigh,  and  mak- 
ing extension  from  the  knee  and  ankle. 

The  relation  of  the  tibia  and  fibula  to  each  other  must 
be  borne  in  mind  in  performing  amputation  through  the 
leg.  The  fibula  lies  on  a  plane  posterior  to  the  tibia, 
and  its  external  border,  with  about  half  of  its  external 
surface,  is  situated  behind  the  interosseous  ligament; 
hence,  unless  care  be  taken,  the  knife  may  be  easily  en- 
tered between  the  bones,  instead  of  taking  the  necessary 
oblique  course  skirting  their  posterior  surfaces. 

Structures  Divided  in  the  Double  Flap  Amputation 
through  the  Calf. — In  the  anterior  flap :  the  integument, 
cutaneous  nerves,  aponeurosis,  tibialis  anticus,  extensor 
communis  digitorum,  and  extensor  proprius  pollicis, 
peroneus  longus  and  brevis,  musculo-cutaneotis  nerve, 
anterior  tibial  vessels  and  nerve.  In  the  posterior,  the 
flexor  longus  digitorum,  flexor  longus  pollicis  and  tibia- 
lis posticus,  posterior  tibial  vessels  and  nerve,  peroneal 
vessels,  intermuscular  aponeurosis,  soleus  and  plantaris, 
gastrocnemius,  external  saphena  nerve  and  vein,  inter- 
nal saphena  vein  and  nerve,  aponeurosis  and  integuments. 

SUKGICAL  ANATOMY  OF  THE  FOOT. 

Ankle  or  Malleolar  Region. — It  has  been  thought 
more  convenient  to  postpone  the  description  of  the  several 
articulations  entering  into  the  conformation  of  the  foot 
and  ankle  until  all  those  soft  structures  which  inclose 
them  have  been  explained ;  as  all  surgical  reference  to 
the  skeleton  must  necessarily  be  made  from  the  surface, 
it  is  of  importance  that  all  the  intermediate  parts  be  de- 


272  SURGICAL    ANATOMY    OF 

monstrated  from  without  inwards,  and  in  the  order  they 
would  be  met  with  in  an  operation. 

Surface  Mar  kings. ^-This  region  includes  the  ankle- 
joint,  and  the  structures  immediately  surrounding  it, 
and  offers  for  examination  two  surfaces,  an  anterior  and 
a  posterior. 

Anterior  Surface. — The  two  malleoli,  of  which  the  in- 
ternal is  the  shorter  and  broader,  and  the  external  set 
more  backwards  and  longer,  inclose  a  space  through  which 
pass  the  extensors  of  the  foot  and  toes,  which  are  ren- 
dered evident  in  their  several  movements.  Beneath  the 
integument  and  superficial  fascia  lie,  internally,  just  in 
front  of  the  malleolus,  the  internal  saphena  vein,  accom- 
panied by  its  nerve ;  more  externally  the  musctilo-cuta- 
neous  nerve,  whilst  passing  from  behind  the  outer  mal- 
leolus is  the  external  saphena  nerve.  The  aponeurosis 
is  a  strengthened  continuation  of  that  of  the  leg,  attached 
intimately  to  the  malleoli,  consisting  of  a  superior  fas- 
ciculus, which  binds  down  the  subjacent  tendons,  just  in 
front  of  the  extremities  of  the  tibia  and  fibula,  and  an 
inferior,  which  retains  them  in  connection  with  the  tarsus. 
It  forms  two  distinct  septa,  commencing  internally — 1, 
for  the  tendon  of  the  tibialis  anticus ;  2,  for  the  tendon 
of  the  extensor  longus  digitorum,  peroneus  tertius,  and 
extensor  proprius  pollicis,  beneath  which  is  the  anterior 
tibial  vessels  and  nerve.  These  sheaths  are  lined  with 
separate  synovial  membranes. 

The  posterior  surface,  or  that  portion  behind  the 
malleoli,  is  separated  by  the  tendo-Achillis  into  two 
hollows.  In  the  outer,  beneath  the  integuments,  is  the 
external  saphena  vein  and  nerve,  lying  upon  the  external 
annular  ligament,  which  is  attached  to  the  outer  malleo- 
lus and  outer  surface  of  the  os  calcis,  binding  down  the 


THE    FOOT.  273 

peroneus  longus  and  brevis,  the  former  being  the  supe- 
rior ;  they  are  contained  in  a  common  sheath  (at  first), 
and  have  a  common  synovial  membrane. 

In  the  inner,  the  pulsations  of  the  posterior  tibial 
artery  are  plainly  seen  or  felt,  and  beneath  the  integu- 
ment are  the  internal  saphena  vein  and  nerve,  which  lie 
upon  the  internal  annular  ligament,  which  is  attached 
to  the  inner  malleolus  and  inner  surface  of  the  os  calcis, 
and  forms  with  the  tibia,  os  calcis  and  astragalus  a  series 
of  separate  canals,  containing  from  before  backwards 
the  tendons  of  the  tibialis  posticus;  the  flexor  longus 
digitorum ;  the  posterior  tibial  vessels  and  nerve,  run- 
ning in  a  sheath  of  their  own  derived  from  the  contigu- 

FIG.  47. 


Relations  of  parts  behind  the  inner  malleolus.  1, 1.  Tibialis  posticus.  2.  Tendo- 
Achillis.  3.  Tibialis  anticus.  4,  4.  Flexor  longus  digitorum.  6.  Posterior  tibial 
artery.  8.  Posterior  tibial  nerve.  The  tendon  of  the  flexor  longus  pollicis  is  too 
deeply  placed  to  be  shown  in  this  view.  (HEATH.) 


ous  septa;  the  flexor  longus  pollicis,  the  canal  of  which 
is  formed  partly  by  the  astragalus.    Each  of  these  canals 
has  a  separate  synovial  membrane.    The  tendo-Achillis 
has  a  separate  sheath  derived  from  this  aponeurosis. 
The  posterior  tibial  artery  at  the  ankle-joint  lies  be- 


274  SURGICAL    ANATOMY    OF 

tween  the  flexor  longus  digitornm  and  the  flexor  longus 
pollicis  tendons,  having  vense  comites  on  each  side,  and 
the  posterior  tibial  nerve  behind  it. 

Ligature  of  the  Posterior  Tibial  Artery  at  the  Inner 
Malleolus. — This  vessel  is  easily  reached,  but  the  incision 
must  be  made  carefully,  as  there  is  a  risk  of  dividing  it 
in  overcoming  the  resistance  of  the  internal  lateral  liga- 
ment. An  incision  about  two  inches  and  a  half  in 
length  is  to  be  made  through  the  integument,  midway 
between  the  inner  malleolus  and  the  tuberosity  of  the 
os  calcis.  After  the  dense  aponeurosis  is  exposed  it 
should  be  cautiously  divided,  when  the  vessel  will  be 
seen  surrounded  by  vena3  cornites,  and  in  order  to  avoid 
the  nerve,  which  lies  posteriorly,  the  needle  should  be 
passed  from  the  heel  towards  the  ankle. 

The  Dorsum  of  the  Foot. — The  chief  points  to  be  ob- 
served in  the  surface  markings  of  the  dorsum  of  the  foot 
are  those  connected  with  the  prominent  points  of  its 
skeleton.  For  the  performance  of  the  several  amputa- 
tions and  disarticulations,  certain  landmarks  are  neces- 
sary to  guide  the  operator  in  finding  the  articulation  he 
desires  to  open.  Thus,  a  line  drawn  from  the  depres- 
sion on  the  inner  side  of  the  foot,  immediately  between 
the  inner  cuneiform  bone  and  the  great  toe,  to  the  poste- 
rior edge  of  the  tuberosity  of  the  fifth  metatarsal  bone, 
indicates  the  course  of  an  incision,  such  as  would  expose 
the  tarso-metatarsal  articulation. 

Again,  the  tubercle  of  the  scaphoid  on  the  inner  side, 
and  a  point  midway  between  the  outer  malleolus,  and  the 
tuberosity  of  the  fifth  metatarsal  bone,  which  is  the 
situation  of  the  articulation  between  the  cuboid  and  os 
calcis,  indicates  a  line  of  incision  which  would  open  the 
medio-tarsal  joint. 


THE    FOOT.  275 

The  structures  met  with  in  dissecting  down  upon  the 
dorsal  aspect  of  the  tarsus  and  metatarsus,  are — the  in- 
tegument, and  subcutaneous  cellular  tissue,  which  con- 
tains the  dorsal  venous  arch,  the  terminal  inosculation 
of  the  internal  and  external  saphena,  and  the  musculo- 
cutaneous  nerves,  beneath  which  is  the  dorsal  aponeuro- 
sis  of  the  foot,  and  from  within  outwards  the  tendons  of 
the  tibialis  posticus,  tibialis  anticus,  extensor  proprius 
pollicis,  extensor  communis  digitorum,  peroneus  tertius, 
and  peroneus  brevis,  and  in  a  plane  beneath  them  the 
extensor  brevis  digitorum  ;  externally,  the  dorsalis  pedis 
vessels  and  anterior  tibial  nerve,  the  tarsal  and  metatar- 
sal  branches  of  the  anterior  tibial  artery  and  external 
branch  of  the  anterior  tibial  nerve,  which  latter  lie  be- 
neath the  lesser  extensor  muscle.  All  these  structures 
lie  close  upon  the  tarsus  and  metatarsus,  and  between 
the  metatarsal  bones  the  dorsal  interossei  are  seen  bulg- 
ing through. 

The  dorsalis  pedis  artery  is  the  continuation  of  the 
anterior  tibial,  and  passes  forwards  on  the  tibial  side  of 
the  foot  to  the  inner  interosseous  space,  where  it  divides 
into  the  dorsalis  hallucis  and  the  perforating  vessels 
which  enter  the  sole  between  the  heads  of  the  first  dorsal 
interosseous  muscle,  and  is  in  relation  in  front  with  the 
integument  and  fascia,  and  inner  tendon  of  the  extensor 
brevis  digitorum  ;  internally  with  the  extensor  proprius 
pollicis ;  externally  with  the  extensor  longus  digitorum 
and  anterior  tibial  nerve ;  posteriorly  with  the  astraga- 
lus, scaphoid,  inner  cuneiform,  and  with  the  ligaments 
attached  to  them. 

Ligature  of  Dorsalis  Pedis  Artery. — The  course  of  this 
vessel  is  indicated  by  a  line  drawn  from  the  middle  of 
the  intermalleolar  space  to  the  first  interosseous  space. 


276  SURGICAL    ANATOMY    OF 

It  is  superficial,  but  is  bound  down  by  a  very  dense 
aponeurosis,  which  must  be  divided  cautiously  to  avoid 
injuring  the  artery  beneath.  An  incision  is  to  be  made 
over  the  instep  along  the  outer  border  of  the  extensor 
proprius  pollicis,  when  the  vessel  will  be  found  lying  in 
a  triangular  interspace  formed  by  the  outer  border  of 
the  extensor  proprius  pollicis  internally,  by  the  inner 
tendon  of  the  extensor  brevis  externally,  and  by  the 
fleshy  fibres  of  the  extensor  brevis  digitorum,  poste- 
riorly. The  nerve  lies  to  its  outer  side. 

SURGICAL  ANATOMY  OF  THE  SOLE  OF  THE  FOOT. 

Dissection. — On  removing  the  integument,  which  is 
very  thick  and  strong,  the  first  tissue  met  with  is  a 
dense  layer  of  fat,  in  which  are  three  bursse,  one  beneath 
the  os  calcis,  and  two  beneath  the  heads  of  the  first  and 
fifth  metatarsal  bones.  Ramifying  in  the  fat  are  some 
cutaneous  branches  of  the  cutaneous  nerves  of  the  foot, 
some  perforating  branches  of  the  plantar  vessels,  and  a 
great  number  of  lymphatics.  The  next  layer  is  formed 
by  the  plantar  fascia,  consisting  of  three  portions,  of 
which  the  central  is  the  strongest,  sending  down  pro- 
cesses which  inclose  the  several  muscles,  separating  the 
middle  from  the  external  and  plantar  groups.  The 
fascia  divides  opposite  the  middle  of  the  metatarsus  into 
five  processes,  each  one  of  which  divides  again  opposite 
the  metatarso-phalangeal  joint  into  two  slips,  which  by 
their  deep  attachments  form  arches  for  the  passage  of  the 
flexor  tendons  to  pass  to  the  toes ;  the  interspace  allows 
of  the  digital  vessels  and  nerves,  the  tendons  of  the 
lumbricales  and  interossei  becoming  superficial.  The 
mutual  relations  of  the  structures  forming  the  sole  of 


THE    SOLE    OF    THE    FOOT.  277 

the  foot  can  be  conveniently  referred  to  the  partitions 
formed  by  the  plantar  fascia.  In  the  inner  compartment, 
internally  and  posteriorly,  lie  the  fleshy  fibres  of  the 
abductor  pollicis,  the  tendons  of  the  flexor  longus  digi- 
torum  and  flexor  longus  pollicis,  the  latter  crossing  and 
becoming  internal  anteriorly,  the  posterior  tibial  vessels 
and  nerves  becoming  plantar,  flexor  brevis  pollicis,  the 
vessels  and  nerves  of  the  great  toe,  and  inner  side  of  the 
foot, 

In  the  outer  compartment  lie  the  abductor  minimi 
digiti,  and  the  flexor  brevis  minimi  digiti. 

The  middle  compartment,  which  is  by  far  the  most 
important  from  its  contents  and  size,  is  bounded  by  the 
plantar  fascia  below,  laterally  by  the  septa  between  the 
outer  and  inner  compartments,  and  its  roof  is  formed  by 
the  under  surfaces  of  the  bones  forming  the  arch  of  the 
foot ;  it  communicates  posteriorly  with  the  region  of  the 
leg  by  means  of  the  sheaths  for  the  tendons  and  vessels 
passing  beneath  the  inner  malleolus.  Beneath  the  mid- 
dle fasciculus  of  the  plantar  fascia,  lie  the  flexor  brevis 
digitorum,  the  plantar  vessels  and  nerves,  the  flexor  ac- 
cessorius,  the  tendons  of  the  flexor  longus  digitorum, 
with  which  are  associated  the  lumbricales,  and  flexor 
longus  pollicis  internally.  Beneath  these  muscles  lie 
posteriorly  the  tarsal  bones  and  their  ligaments,  ante- 
riorly, the  adductor  pollicis,  the  heads  of  the  metacarpal 
bones  and  the  ligaments  uniting  them,  the  transversus 
pedis,  the  plantar  arch  and  external  plantar  nerve  and 
their  interosseal  branches,  the  bodies  of  the  metacarpal 
bones,  between  which  lie  the  plantar  interossei,  and  lying 
deeply  in  the  tarsus  the  tendon  of  the  peroneus  longus. 

The  Ankle-joint  and  Articulations  of  the  Foot. — The 
structures  immediately  in  relation  with  the  ankle-joint  are, 

24 


278  SURGICAL    ANATOMY    OF 

anteriorly,  the  tendons  of  the  extensor  longus  digitorum 
and  peroneus  tertius,  the  extensor  proprius  pollicis,  an- 
terior tibial  vessels  and  nerve,  the  tendon  of  the  tibialis 
anticus;  posteriorly,  tendons  of  the  peroneus  longus  and 
brevis,  the  flexor  longus  pollicis,  the  posterior  tibial  ves- 
sels and  nerve,  the  tendons  of  the  flexor  longus  digito- 
rura  and  tibialis  posticus. 

The  joint  is  formed  by  the  articulation  of  the  inferior 
articular  extremities  of  the  tibia  and  fibula  with  the  as- 
tragalus. 

The  Tibio-tarsal  Articulation. — The  extremities  of  the 
tibia  and  fibula  are  hollowed  out  into  a  sort  of  mortice, 

FIG.  48. 


Section  of  the  right  ankle.  1.  Extensor  longus  digitorum  and  peroneus  ter- 
tius.  2.  Peroneus  longus.  3.  Extensor  proprius  pollicis.  4.  Peroneus  brevis. 
5.  Anterior  tibial  vessels  and  nerve.  6.  Flexor  longus  pollicis.  7.  Tibialis  anti- 
cus. 8.  Tendo-Achillis.  9.  Tibialis  posticus.  10.  Plantaris.  11.  Flexor  longus 
digitorum.  12.  Posterior  tibial  vessels  and  nerve.  (HEATH.) 

concave  from  before  backwards,  open  in  front  and  be- 
hind, and  shut  in  laterally  by  the  malleoli.  The  use  of 
the  malleoli  is  to  prevent  lateral  movements,  and  to  re- 
strict the  motions  of  the  joint  to  flexion  and  extension. 
The  articular  surface  of  the  astragalus  presents  superi- 


THE    SOLE    OF    THE    FOOT.  279 

orly  a  surface  convex  from  before  backwards  for  the  cor- 
responding articular  surface  of  the  tibia ;  laterally  are 
two  articular  surfaces  corresponding  with  those  of  the 
malleoli,  the  external  one  being  the  larger.  The  liga- 
ments are  an  external  lateral,  consisting  of  three  fas- 
ciculi ;  an  internal,  or  deltoid,  radiating  from  the  inner 
malleolus,  to  be  attached  to  the  scaphoid,  os  calcis,  and 
astragalus ;  anteriorly  are  a  few  fibres  closing  in  the  ar- 
ticulation ;  posteriorly  the  joint  is  shut  in  by  the  trans- 
verse ligament  of  the  inferior  tibio-fibular  articulation. 
The  synovial  membrane  invests  the  inner  surface  of  the 
ligaments  and  articular  cartilages,  and  owing  to  the 
great  laxity  of  the  anterior  and  posterior  ligaments  it 
readily  bulges  through  them,  consequently  the  joint  is 
easily  reached  from  either  aspect,  and  in  cases  of  syno- 
vitis  the  membrane  usually  protrudes  in  front  between 
the  malleoli  and  again  behind  the  external  malleolus. 

Dislocation  at  the  Tibio-tarsal  Articulation — that  is  to 
say,  dislocation  of  the  entire  foot  from  the  bones  of  the 
leg — is  almost  invariably  associated  with  fracture  of  one 
or  other  malleoli,  which  can  be  readily  understood  from 
the  shape  and  extent  of  motion  allowed  at  the  joint.  It 
is  a  result  of  the  foot  being  twisted  in  running  or  walk- 
ing, and  may  either  be  outwards,  when  the  lower  end  of 
the  fibula  is  broken,  the  inner  malleolus  or  internal  lat- 
eral ligament  torn ;  internal,  when  there  is  no  fracture 
of  the  fibula,  but  the  lower  end  of  the  tibia  is  broken ; 
backwards,  when  both  malleoli  are  broken,  and  the  heel 
projecting;  and  forwards,  when  the  astragalus  is  thrown 
in  front  of  the  tibia. 

Excision  of  the  Ankle-joint  (tibio-tarsal). — The  seat  of 
the  disease  can  be  reached  by  a  variety  of  incisions ;  but 
the  object  to  be  attained  is  to  save  the  tendons,  in  order 


280  SURGICAL    ANATOMY    OF 

that  they  may  still  fulfil  their  functions  as  far  as  possible, 
and  an  accurate  knowledge  of  the  parts  in  contact  with 
the  articulation  is  necessary.  The  integument  only 
being  divided  by  an  incision  which  commences  just 
above  and  behind  the  outer  malleolus  and  extending 
across  the  joint  to  a  corresponding  point  above  the 
inner,  the  flap  being  dissected  back,  the  peronei  tendons 
are  to  be  dislodged  and  the  external  lateral  ligament 
divided.  In  order  to  obtain  access  to  the  joint  on  the 
outside,  the  lower  end  of  the  fibula  is  to  be  snipped  off, 
and  its  connection  with  the  tibia  severed.  Next,  to  get 
at  the  inner  aspect  of  the  articulation,  the  flexor  com- 
mtinis  digitorum  and  tibialis  posticus  tendons  are  to  be 
dissected  from  behind  the  inner  malleolus,  and  care 
taken  to  avoid  the  posterior  tibial  vessels  and  nerve. 
The  lower  end  of  the  tibia  can  now  by  a  wrench  be  dis- 
located through  the  wound ;  the  diseased  surfaces  are 
then  to  be  removed  (Hancock).  The  diseased  surfaces 
can  be  reached  and  removed  by  two  lateral  incisions 
(Barwell). 

The  articulation  of  the  astragalus  with  the  os  calcis 
is  one  of  great  strength,  owing  to  the  interosseous  liga- 
ments which  lie  in  the  grooves  of  these  bones ;  it  is  rup- 
tured in  cases  of  dislocation  of  the  astragalus  from  the 
os  calcis.  This  is  by  far  the  most  important  of  the  lux- 
ations of  the  tarsal  bones,  and  may  occur  either  forwards 
and  inwards,  or  forwards  and  outwards,  or  backwards. 

Amputation  at  the  Ankle-joint. — The  landmarks  for  the 
guidance  of  the  knife  are,  in  the  first  place,  for  the  an- 
terior flap,  the  two  malleoli,  which  are  to  be  united  by 
a  semilunar  incision ;  and  for  the  posterior,  one  cutting 
the  sole  transversely  and  a  little  obliquely  forwards,  and 
extending  between  the  limits  of  the  preceding  incision ; 


THE    SOLE    OF    THE    FOOT.  281 

the  articulation  is  opened,  and  the  lateral  ligaments  di- 
vided, the  posterior  part  of  the  capsule  cut  through,  and 
the  os  calcis  sawn  through  obliquely  from  behind  for- 
wards and  downwards.  The  anterior  flap  is  dissected 
off  the  malleoli,  which  are  next  sawn  off,  and  the  cut 
surfaces  approximated,  and  the  tendo-Achillis,  per- 
haps, divided.  (Pirogoff.)  Syme's  amputation  consists 
in  removing  the  os  calcis,  and  sawing  off  the  ends  of  the 
malleoli.  In  both  these  operations  care  must  be  taken 
not  to  wound  the  trunk  of  the  posterior  tibial  artery, 
and  to  keep  the  external  and  internal  plantar  vessels  as 
long  as  possible. 

Club-foot  (Talipes). — The  various  deformities  of  the 
foot,  occurring  at  the  tibio-tarsal  or  medio-tarsal  articu- 
lations, which  are  within  the  operative  interference  known 
as  tenotomy,  are — talipes  equinus,  in  which  the  heel  is 
raised  so  that  the  individual  walks  on  the  ball  of  the 
foot,  in  which  case  the  tendo-Achillis  requires  division ; 
talipes  varus,  or  more  precisely  talipes  equino-varus, 
where  the  heel  is  raised,  the  foot  turned  inwards  for 
about  the  anterior  two-thirds — this  inversion  taking 
place  at  the  astragalo-scaphoid  and  calcaneo-cuboid  ar- 
ticulations, its  dorsal  aspect  outwards,  and  the  inner 
edge  drawn  up ;  the  tendons  requiring  division  being, — 
the  tendo-Achillis,  and  the  tendons  of  the  tibialis  posti- 
cus,  anticus,  and  flexor  longus  digitorum ;  talipes  valgus, 
where  the  inner  ankle  is  towards  the  ground  and  the 
outer  edge  of  the  foot  turned  up ;  the  tendons  to  be  di- 
vided are, — the  peronei,  and  the  extensor  longus  digi- 
torum, and  the  plantar  fascia ;  talipes  calcaneus,  where 
the  patient  walks  on  the  heel, — a  case  requiring  division 
of  the  tendons  of  the  tibialis  anticus,  extensor  communis 
digitorum,  extensor  proprius  pollicis,  and  peroneus  ter- 


282  SURGICAL    ANATOMY    OF 

tius.  There  are  several  intermediate  forms;  this  is  owing 
to  the  fact  that  the  posterior  tibial  nerve  supplies  the 
gastrocnemius  and  soleus,  which  terminate  in  the  tendo- 
Achillis,  and  the  tibialis  posticus.  Again,  talipes  equinus 
and  varus  are  usually  associated,  because  the  extensor 
and  peronei  muscles  are  supplied  by  the  anterior  tibial 
and  musculo-cutaneous  nerve.  Talipes  calcaneus  and 
valgus  are  generally  associated. 

The  tibialis  posticus  tendon  is  divided  in  tenotomy, 
either  above  or  below  the  ankle.  The  point  selected 
above  the  ankle  is  on  the  posterior  margin  of  the  tibia 
about  an  inch  or  so  above  the  malleolus,  where  it  lies  in 
the  groove  in  its  own  sheath  and  in  contact  with  the 
bone ;  eversion  of  the  foot  tenses  the  tendon  below  the 
ankle,  at  its  insertion  into  the  scaphoid.  The  point  is 
just  above  the  astragalo-scaphoid  articulation,  which  is 
immediately  behind  the  first  tuberosity  met  with  in  pass- 
ing the  finger  along  the  inner  side  of  the  foot,  starting 
at  the  malleolus.  The  tibialis  anticus  not  being  so  con- 
fined as  the  preceding  can  be  more  readily  put  on  the 
stretch,  as  it  passes  over  the  lower  end  of  the  tibia  in  the 
innermost  compartment  of  the  annular  ligament.  It  may 
be  also  divided  at  its  insertion  into  the  inner  cuneiform 
bone,  the  position  of  which  attachment  may  be  ascer- 
tained by  passing  the  finger  along  the  inner  surface  of 
the  foot,  when  it  is  just  in  front  of  the  articulation  of  the 
scaphoid  with  the  inner  cuneiform. 

In  performing  the  tarso-metatarsal  disarticulation, 
known  as  Hey's  or  Lisfranc's,  the  line  of  the  joint  may 
be  exposed,  in  the  first  place,  by  starting  from  the  outer 
surface  of  the  foot  from  a  point  immediately  behind  the 
tuberosity  of  the  fifth  metatarsal  bone  to  a  point  which 
may  be  indicated  in  one  of  the  following  ways :  (1)  If 


THE    SOLE    OF    THE    FOOT. 


283 


a  transverse  line  be  drawn  across  the  foot  from  the 
tuberosity  of  the  fifth  metatarsal  bone,  it  falls  on  the 
inside  of  the  foot,  two-thirds  of  an  inch  behind  the  re- 
quired spot ;  (2)  in  following  the  inner  edge  of  the  foot 
from  behind  forwards,  an  inch  in  front  of  the  malleolus 
is  the  projection  of  the  scaphoid  ;  the  joint  is  one  inch  in 
front  of  this.  The  articulation  of  the  first  metatarsal 
bone  with  the  inner  cuneiform  is  oblique  from  within 
outwards,  and  about  a  quarter  of  an  inch  in  front  of  the 
third.  The  line  of  the  joint  is  rendered  irregular  by  the 
jutting  into  the  tarsus  of  the  second  metacarpal  bone, 
which  is  wedged  in  between  the  inner  and  outer  cunei- 
form bones,  its  line  of  articulation  lying  about  half  an 
inch  behind  the  anterior  articular  surface  of  the  inner 


FIG.  40. 


Rough  sketch  of  portion  of  tarsus  removed  in— A.  Key's  amputation. 
B.  Chopart.    D.  Roux.    c.  Pirogoff. 

cuneiform,  and  about  a  quarter  of  an  inch  behind  the 
anterior  articular  surface  of  the  outer  cuneiform  bone. 
The  joint  of  the  third  with  the  scaphoid  is  almost  trans- 
verse :  that  of  the  fourth  is  curved  ;  and  that  of  the  fifth 


284    •  SURGICAL    ANATOMY    OF 

with  the  cuboid  is  doubly  oblique.  After  disarticulation, 
the  posterior  flap  should  extend  as  far  as  the  web  of  the 
toes. 

Parts  Divided  in  Hey's  Amputation. — In  the  anterior 
flap,  the  integument  beginning  from  the  outer  side,  the 
dorsal  veins  of  the  foot,  the  internal  and  external  divis- 
ions of  the  musculo-cutaneous  nerve,  the  internal  and 
external  cutaneous  nerves,  the  dorsal  aponeurosis,  exten- 
sor brevis  digitorum,  tendon  of  peroneus  brevis,  tendon 
of  extensor  communis  digitorum,  anterior  tibial  vessels 
and  nerve,  tendons  of  extensor  proprius  pollicis  and  tibi- 
alis  anticus,  dorsal  ligaments,  and  the  articulation. 

In  the  posterior  flap,  plantar  ligaments,  tendon  of 
peroneus  longus,  external  and  internal  plantar  vessels 
and  nerves,  interossei,  the  flexor  brevis,  abductor  and 
adductor  pollicis,  transversus  pedis,  tendons  of  long  and 
short  flexors  of  toes,  and  flexor  longus  pollicis  tendon, 
djgital  vessels  and  nerves,  plantar  fascia  and  integument. 

Chopart's  amputation,  or  the  inedio-tarsal,  consists  of 
opening  the  articulation  by  a  semilunar  incision,  extend- 
ing between  the  joint  behind  the  tubercle  of  the  scaphoid 
internally  and  a  point  midway  between  the  external 
malleolus  and  the  tuberosity  of  the  fifth  metatarsal  bone; 
externally,  the  posterior  flap  is  to  be  brought  well  up  to 
the  web  of  the  toes. 

It  is  important  to  remember  that  the  direction  of  the 
articulating  surface  is  changed  in  flexion  or  extension : 
in  flexion  the  astragalus  and  calcis  are  in  the  same  line, 
in  extension  the  calcis  is  at  least  a  quarter  of  an  inch  in 
front ;  the  head  of  the  astragalus  presents  a  large  globu- 
lar surface,  whilst  the  anterior  articulating  surface  of  the 
calcis  is  concave. 

The  following  directions  for  discovering  the  articula- 


THE    SOLE    OF    THE    FOOT. 


285 


tion  with  readiness  are  useful.  To  find  its  internal  side, 
follow  the  inner  edge  of  the  foot  with  the  finger ;  the 
first  tuberosity  met  with  is  the  scaphoid;  the  joint  is  im- 
mediately behind  it.  For  the  external  side,  pass  the  fin- 
ger along  the  outer  edge  of  the  foot  from  the  external 
malleolus ;  the  articulation  is  immediately  in  front  of  the 
first  tuberosity  met  with,  which  belongs  to  the  os  calcis. 


FIG.  50. 


A.  Line  of  Chopart.    B.  Lice  of  Hey.    c.  Tubercle  of  fifth  metatarsal. 
D.  Tubercle  of  scaphoid. 


For  its  middle  and  superior  portion,  extend  the  foot  and 
abduct  it ;  then,  applying  the  finger  on  the  union  of  the 
external  with  the  middle  third  of  the  intermalleolar 
space,  the  first  eminence  met  with  in  proceeding  forwards 


286  SURGICAL    ANATOMY    OF 

is  the  head  of  the  astragalus ;  immediately  in  front  of 
this  is  the  articulation.     (Malgaigne.) 

Structured  Divided  in  Chopart's  Amputation. — Com- 
mencing from  the  inner  side,  the  anterior  flap,  that  is,  up 
to  the  point  of  clisarticulation,  will  contain  integument, 
saphena  vein,  and  musculo-cutaneous  nerve,  anterior  an- 
nular ligament,  tendon  of  tibialis  anticus,  extensor  pro- 
prius  pollicis,  anterior  tibial  nerve  and  vessels,  tendons 
of  common  extensor  and  peroneus  tertius,  extensor  brevis 
digitorum,  peroneus  brevis  and  anterior  ligaments  of  the 
articulation ;  the  posterior  flap  should  contain  the  poste- 
rior ligaments  of  the  articulation,  the  tendon  of  the  tibi- 
alis posticus,  flexor  longus  digitorum  and  flexor  longus 
pollicis,  some  branches  of  the  internal  plantar  nerve  and 
vessels,  the  abductor  pollicis,  the  flexor  accessorius,  the 
tendon  of  the  peroneus  longus,  the  abductor  minimum 
digiti,  the  flexor  brevis  digitorum,  the  external  plantar 
nerve  and  vessels,  and  the  integument  of  the  sole. 

Synovial  Membranes  of  the  Tarsus  and  Metatarsus. — 
There  are  four  synovia!  membranes  in  the  articulations 
of  the  tarsus — namely,  one  for  the  posterior  calcaneo-as- 
tragaloid  articulation,  a  second  for  the  anterior  calcaneo- 
astragaloid  and  astragalo-scaphoid,  a  third  for  the  calca- 
neocuboid,  and  a  fourth  for  the  surfaces  of  the  cuneiform 
with  the  scaphoid,  the  cuneiform  with  each  other,  the 
external  cuneiform  with  the  cuboid,  and  the  middle  and 
outer  cuneiform  with  the  second  and  third  metatarsal 
bones.  Between  the  internal  cuneiform  and  the  base  of 
the  metatarsal  bone  of  the  great  toe  there  is  a  single 
sy  no  vial  membrane,  and  there  is  another  common  to  the 
anterior  surface  of  the  cuboid,  and  the  bases  of  the  fourth 
and  fifth  metatarsal  bones. 

The  arteries  of  the  sole  of  the  foot  are  the  internal  and 


THE  SOLE  OP  THE  FOOT.          287 

external  plantar ;  the  internal  commences  at  about  the 
centre  of  the  inner  aspect  of  the  os  calcis,  and  courses 
forwards  between  the  muscles  of  the  inner  and  middle 
groups,  anastomosing  with  the  malleolar  and  dorsalis 
pedis.  The  external  is  much  larger,  and  forms  the 
plantar  arch.  Commencing  at  the  same  spot  as  the  in- 
ternal, it  passes  obliquely  forwards  and  outwards,  lying 
at  first  between  the  os  calcis  and  abductor  pollicis,  and 
then  between  the  flexor  accessories  and  flexor  brevis,  and 
forming  a  curve,  the  convexity  of  which  is  forwards,  it 
joins,  at  the  interval  between  the  first  and  second  meta- 
tarsal  bones,  the  perforating  branch  of  the  dorsalis  pedis, 
thus  completing  the  plantar  arch.  Its  branches  are 
muscular,  perforating,  which  inosculate  with  those  of  the 
metatarsal  artery,  and  digital,  which  supply  the  three 
outer  toes  and  half  the  second. 

The  nerves  are  the  internal  and  external  plantar 
branches  of  the  posterior  tibial,  of  which  the  internal  is 
considerably  the  larger. 

Toes. — The  description  already  given  of  the  fingers 
will  in  almost  every  particular  suffice  for  that  of  the 
toes. 


INDEX. 


PAGE 

Abdomen,  region  of,  .         .         . 168 

Abdominal  parietes,          .........     169 

ring,  external 173,  175 

internal, 177 

relation  of,  to  surface,      .         .         .         .         .         .178 

Abscess,  axillary, 132 

in  face 25 

in  groin,       ........          .         .     183 

in  uiastoid  cells, 17 

iliac, 189,   196 

ischio-rectal, 209 

of  liver, 115 

lumbar 196 

mammary.   .         .         .         .         .         .         .         .         .         .113 

of  tongue, 62 

orbital, 41 

palmar, 165 

parotid, 56 

pelvic, 189,  196 

popliteal, 259 

psoas, 196 

prostatic, 210,  211 

retro-pharyngeal 64 

thecal 166 

tonsillar,      .         .         .         .         .         .         .         .         .         .51 

vulval, 223 

Accelerator  urinse  muscle,          .          .         .         .         .         .  .     203 

Action  of  muscles  in  fracture  of  clavicle, 123 

of  femur, 244-253 

of  humerus,  head  of,  .  .  .  .145 
lower  extremity  of,  .  .  145 
shaft  of,  .  .  .  .145 

of  patella 261,  263 

of  radius,      .         .         .         .         .         .156 

of  ulna, 156 

dislocation,  of  femur, 243 

of  humerus,     .         .         .         .         .127 

of  patella, 263 

Amussat's  operation, 194 

Anal  region 206 

Anastomotica  magna,  brachial  artery  of, 144 

femoral  artery  of, 252 


290  INDEX. 


*  PAGE 

Ankle-joint,  amputation  at,       ........     280 

excision  of,    .........     279 

Anus,  artificial,          ..........     188 

fissure  of,          ..........     206 

fistula  of,          ..........     207 

Aorta,  orifice  of,        ..........     109 

Arch  of  aorta  .....         .......     109 

crural,       ...........     173 

palmar,     ..........     162,   165 

plantar,     ...........     287 

Arm  (fore)  region  of,         .         .         .         .         .         .         .         .         .151 

fractures  of,     .........     157 

dislocations  of,        ........     151 

Astragalus,         ...........     280 

Auditory  meatus,  external,        ........       21 

inspection  of,         .         .         .         .         .         .         .21 

Auriculo-  ventricular  opening,  right,          .         .         .         .         .         .108 

left,    .......     109 

Axilla,  region  of,       ..........     131 

Axillary  artery,         ...  .....       135-137 

ligature  of,       ........     138 


Base  of  skull,  fractures  of,         ........  20 

Bend  of  elbow, 146 

Bladder 226 

Brachial  region, 140 

artery, 143 

ligature  of,  above  bend  of  elbow 143 

at             """....  148 

Bronchi 81 

Bulb  of  urethra, 214 

artery  to 214,  216 

Bursa  beneath  deltoid 124 

gluteus  maximus,    .........  237 

patellae 254 


Canal,  crural,   ........... 

inguinal, 178 

nasal,     ........... 

obturator, 238 

Canaliculi,         .         .         .         .         .         ...         .         .         .         .36 

Capsule  of  hip, 242 

knee 261 

shoulder 126,  127 

Caries  of  vertebra; 116,118 

Carotid  region,  .         .         .         .         .         .         .         .         •         .81 

common,       ..........       86 

ligature  of,       .......         88,  8i 

external, 

ligature  of,      ........ 

internal, 87 

Carpus, 158 

Castration, 201 


INDEX.  291 


PAGE 

Catheterism  of  male  urethra, 220 

female, 221 

Cephalhaematoma,      ..........       16 

Chopart's  amputation,       .........     284 

Circumflex  branch  of  axillary  artery,         ......     135 

of  femoral  artery, 234,  235 

Clavicle,  fracture  of, 122 

Club  foot, 281 

Collateral  circulation  after  ligature  of  axillary,         ....     139 

brachial,         ....     144 

carotid,  common,  ...       91 

external,        .         .          .         .91 

femoral,          ....     236 

iliac,  common,       .         .         .     190 

external,       .         .         .192 

internal,       .         .         .229 

innoininata,   .  .         .99 

subclavian,    ....       97 

Colles's  fracture, 161 

Colon, 194 

Compression  of  axillary  artery, 132 

bracbial, 143 

carotid,  common, 90 

external,       .......       56 

femoral 235 

subclavian, 94 

Conjoined  tendon,     .         .         .         .         .         .         .         .         .         .171 

Conjunctiva, 36 

Contre-coup,      ...........       20 

Cord,  spermatic, 200 

Cranial  region,  .         .         . 13 

Cranium,    .          ...........        17 

Cremaster  muscle,     ..........     176 

Crural  region, 182 

arch, 175 

deep 184 

hernia 186 


Dartos, 197 

Diaphragm,  region  of,  .         .         .         .         .         .         .         .114 

Digital  arteries  of  foot, 286 

hand 165 

Dislocation  of  ankle, 279 

carpus 161 

femur, 243 

humerus, 128 

patella, 261 

thumb, 167 

ulna,           .         . 151 

vertebrae,   .         .         .         .         .         .          .         .         .104 

Dissection   of  axill#, 132 

bend  of  elbow, 143 

brachial  region,           .......  140 

carotid  region 82 


292  INDEX. 


PAGE 

Dissection  of  crural  region, 183 

face,  ..........  22 

femoral  region, 248 

forearm,       .........  152 

glutenl  region,      ........  237 

infra-hyoid  region,       .         .         .         .         .         .         .  76 

inguinal  region,  .  .  .  .  .  .  .  .173 

leg, 265 

lumbar  region,  ........  193 

malleolar  region, 272 

nape  of  neck,  ........  103 

nasal  region, 28 

orbit, 39 

occipito-frontal  region, 13 

palm, 163 

parotid  region 54 

plantar  region,  ........  276 

popliteal  space, 257 

pterygo-maxillury  region, 57 

perineum, 202-210 

submaxillary  region 71 

subclavian  region,  .......  95 

superior  maxillary  region, 45 

temporo-parietal  region,       .         .         .         .         .         .16 

wrist 158 

Dorsalis  pedis  artery 275 

Dorsum  of  foot, 274 

hand, 158 

Dura  mater, 18,  21 


Elbow,  amputation  at 150 

bend  of, 146 

dislocation  of, .         .151 

excision  of,    ..........     148 

region  of,       .         .         .         .         .         .         .         .         .         .146 

Emphysema, 110 

Empyema,          .         .         .         .         .         .         .         .         .         •         .111 

Epigastric  artery,  deep, 171 

superficial, 175 

Epiphora 

Epiphysis  of  humerus 129,  145,  151 

femur,    ..........     263 

radius,   .         .         .         .         .         .         .         .         .         .161 

tibia. 265 

Extravasation  of  urine,     .         .         .         .         .         .         .         .         .     199 

Eyeball 41 

Eyelids, 35 

Face,  region  of, 

Facial  artery,     ........... 

Fascia,  anal, 208 

axillary, •  136 

bicipital, 147 


INDEX.  293 


Fascise,  brachial,       ..........     141 

cervical,         .         .          .         .          .         .         .         .         .         .68 

cribriform 183 

iliac, 189.  196 

intercolutnnar, 175 

lata, 249 

lumbar, 195 

obturator, 223 

palmar,          .         .         .         .         .         .          .         .         .         .164 

perineal,  male, 203-205 

female, 222 

pharyngeal,  ..........       64 

plantar,          .         .         .         .         .         .         .         .         .         .276 

popliteal, 256 

recto-vesical, 224 

temporal, 16 

transversalis,         .........     176 

Femoral  region,  superior,  .........     231 

middle 247 

artery,  common,  .........     233 

superficial, 250 

ligature  of, 235,  251 

deep, 233 

in  Hunter's  canal, 250 

ligature  in, 251 

Feinur,  fractures  of, 244-253 

dislocation  of, 243 

Fingers,  region  of,     ..........     165 

amputation  of, 166 

Fissure  of  anus,          .  206 

palate,       .         .         .         .         .         .         .         .          .         .51 

Fistula  in  ano, 209 

lachrymal 39 

salivary,         ..........       56 

Fontanelles, 18 

Foot,  region  of,  ..........     276 

Fossa,  ischio-rectal. 208 

nasal, 28 

navicular,        .         .         .         .         .         .         .       ,\.         .         .218 

Frasnum  linguae, 63 

prseputii 216 


Ganglion,           .         .         .         .         .         .         .         .....  160 

Glands,  axillary, 133,  137 

cervical, 84,  103 

Cowper's,      ..........'  210 

inguinal,       . 175 

lachrymal,    ..........  36 

mammary, 112 

parotid,         ..........  53 

popliteal,      ..........  259 

prostate, 211 

submaxillary,        .........  72 

Glans  penis, 216 

25 


294  INDEX, 


PAGE 

Gluteal  region, 236 

artery,  ligature  of, 237 


Hsematocele, 201 

Haemorrhoidal  arteries, 209 

veins, 208 

Harelip, 47 

Heart 107-115 

Hernia,  diaphragmatic .         .         .  115 

inguinal,       ..........  178 

direct, 181 

femoral  oblique,   .........  179 

obturator, 239 

pudendal, 222 

sciatic, 238 

umbilical, 172 

ventral, 172 

Hip-joint,  region  of, 249 

amputation  at,  .........  246 

excision  of, 246 

dislocation  of, 243 

Humerus,  fractures  of,       ....'...       128,  145,  151 

dislocation  of,   .........  128 

excision  of  head  of, 131 

Hydrocele, 201 

congenital, 181 

Hyoid  region, 75,  77 


Iliac  fossa,         - 189 

artery,  common,       .         .         .         .         .  *  .          .         .     189 

ligature  of, 190 

external, .         .191 

ligature  of, 191 

internal, 228 

ligature  of, 229 

Inguinal  region,         ..........     173 

Innominata,      * 98 

ligature  of, 99 

Inspiration,  diaphragm  in, 114 

lung  in,  .........     107 

subclavian  triangle  during,    ......       93 

Intercostal  muscles,  .         .         .         .         .         .         •         •         •         .110 

artery Ill 

Introduction  of  aural  speculum,        .......       21 

catheter,  male,          .         .         .  .         .-        .220 

female 221 

probe  into  canaliciilus,     ...... 

Eustachian  tube,      ..... 

nasal  duct, 31 

oesophagus  tube,        ........ 

rectum  bougie, 207 


INDEX.  295 


PAGE 

Knee,  region  of, 253 

joint, .260 

excision  of, 265 

Kidney, 169 


Lachrymal  apparatus 36 

gland, 36 

Laryngotomy, 80 

Larynx,     ............  79 

Leg,  region  of,  ...........  265 

Ligament,  annular,  of  ankle 273 

wrist 159 

Giinbernat's, 184,  185 

Key's 183 

Poupart's 171,  173 

Ligature  of  axillary  artery, 138 

anterior  tibial 267 

brachial,           .         .         .         .'        .         .          .       143,  144,  147 

carotid, 89,  90 

dorsalis  pedis, 275 

femoral  (vide  Femoral  Artery), 
iliac,  internal  (vide  Iliac  Arteries). 

innominata, 99 

intermammary,        .         .         .         .         .         .          .         .112 

lingual 73 

mammary,  internal,         .         .         .         .          .         .         .111 

popliteal, 259 

posterior  tibial, '    .  269 

radial, 155 

subclavian,  third  part  of  course, 97 

ulnar 155 

Lingual  region,           ..........  61 

artery, 73 

Lips, 25 

Lithotomy  in  male,    ..........  212 

female, 222 

child 214 

Lithotrity, 222 

Liver,  percussion  of, 169 

Lumbar  colotomy,     ..........  194 

fascia, 195 

Lungs,       ......          ......  107 


Malar  bone, 45 

tubercle,           .         .                   .......  60 

Malleolus,  inner, 273 

outer,        .........'.  272 

Mammae, 112 

excision  of, 114 

Mammary  artery,  internal, Ill 

Mastoid  process, 17 

abscess.  17 


296  INDEX. 


PAGE 

Maxilla,  superior 45 

excision  of.  .........       45 

„    inferior, 58-71 

Maxillary  artery,  internal,         ........       58 

Mediastina, 119 

Meningeal  artery,      ..........       18 

Metnbrana  tympani, 21 

Metacarpal  bone  of  thumb,        .         .         .         .         .         .         .         .164 

amputation  of,        .         .         .        .         .164 

Metacarpus,       .         .         .         .         .         .         .         .         .         .     164,  165 

Mylo-hyoid  muscle, 72 


Nape,  region  of, 102 

Nasal  fossae, ". 28 

Naso-pharyngeal  region,    .........  34 

Neck,  region  of, 66 

fascise  of, 69 

Nose,  region  of,                                      26 

Nostrils,  syringing,   ..........  33 

Nutrient  arteries  of  humerus, 144 

of  tibia, 270 


Obturator  artery, 187,  239 

hernia, 239 

region,       ..........     239 

Occipito-frontal  region,      .         .         .         .         .         .         .         .         .13 

Occipital  region, 101 

artery, 103 

GEsophagus 100 

03sophagotomy,          .         .         .         .         .         .         .         .         .         .101 

Olecranon, 146 

Orbital  region,  external,    .........       35 

internal, 39 

Outlet  of  pelvis, 201,  209 


Palate,  region  of, 48 

cleft, 48 

Palm, 162 

Palmar  arch,  wounds  of,    .         .         .         .         .         .         .         .         .165 

Paracentesis  thoracis,         .         .         .         .         .         .         .         .         .      110 

abdominis,     .........     171 

Paralysis  of  dinphragm,    .         .         .         .         .         .         .         .         .115 

after  injury  in  dorsal  region,      ......     118 

cervical  region, ,104 

of  third  nerve,    .........       43 

of  fourth  nerve, 43 

of  sixth  nerve,   .........       43 

facial, 25 

Parotid  gland,  duct  of, 25 

facial  part  of,     ........       25 

region, 53 


INDEX.  297 


Parts  beneath  deltoid 124 

gluteus  tnaximus, 239 

pectoralis  major,           .         .         .         .         .  137 

mylo-hyoid, 72 

sterno-mastoid,    ........  83 

Perineal  region 266,  267 

artery, 270 

Phalanges  of  fingers,          .         .         .         .         .         .         .         .         .166 

toes, 287 

Pharynx 64 

Phiraosis 217 

Penetrating  wounds  of  thorax,  .         .         .'       .         .         .115,116 

Penis, 216 

Pericranium,      ...........  14 

Perineum, 201 

Plantar  region,           ..........  276 

fascia ' 276 

Pleura, 119 

Polypus, 34 

Popliteal  space, 256 

artery, "...  258 

Pouch,  recto-vesical,          .........  225 

Poupart's  ligament, 173 

'Prostate  gland, 211 

Psoas  muscle  (vide  Abscess). 

Pterygoid  region, 56 

Pudic  artery 209 

Pulmonary  orifice, 109 

Puncta  lachrymalia,           .         .         .         .         .         .         .                 •  .  37 

Puncture  of  bladder  over  pubes, 227 

per  rectum, 227 


Radial  artery, 154,155,160 

Recti  muscles  of  eye,         .         .         .         .         .         .         .         .         .41 

abdomen,        .         .         .         .         .         .         .         .169 

Rectum, 207,  218,  219 

Relations  of  bony  prominences  at  elbow,  .....      146,  151 

at  hip, 231 

at  knee,     ....      254,  260,  261 

at  shoulder 121 

at  wrist, 161 

Relations  of  viscera  to  abdominal  walls 168 

thoracic  walls,       ........     107 

Ring,  external  abdominal 175 

internal,  ...........     ]77 

crural, 185 

Round  ligament  of  hip,     .         .         .         .          .         .         .         .         .      243 


Sac  of  hernia, 180 

lachrymal. 38 

Scalene  tubercle 95 

Scarpa's  triangle 233,  248 


298  INDEX. 


PAGE 

Scrotum 197 

Septum  crurale,         ....          ......     185 

Sheath  of  axillary  vessels, 136 

carotid, 86 

crural, 184 

Shoulder,  region  of, 121 

joint, 126 

Sinus,  lateral,  of  skull, 22 

Spermatic  artery,       ..........     200 

Sphincter  ani 206 

Spina  bifida 104,  223 

Sternal  region, 109 

Sterno-mastoid  region,      .........       81 

Sternum, 110 

Strabismus, 43,  44 

Structures  divided  in  amputation  at  ankle-joint,       ....     281 

arm,  upper,       .         .         .141,   142 

elbow-joint 150 

forearm,    .         .         .         .         .156 
hip-joint,  .         .         .         .246 

knee-joint,  .         .         .     264 

leg, 271 

medio-tarsal,     ....     286 

shoulder-joint,  .         .         .     130 

tarso-metatarsal,       .         .         .     283 

thigh,        .         .         .         .         .     252 

Amussat's  operation,       .         .         .         .         .194 

Caliisen's  operation,        ....  194 

cleft  palate, 51 

cutting  down  on  cranium  in  occipito-frontal 

region,    ....       15 

temporo-parietal,         .         .       17 
excision  of  elbow,    ......     148 

extirpation  of  eyeball,     .....       44 

testis, 201 

fistula  in  ano, 209 

harelip, 47 

head  of  femur,          ......     245 

head  of  humerus,    .         .         .         .         .         .129 

hernia, 182 

knee-joint,       .......     265 

laryngotomy,  ......       80 

ligature  of  iliac  arteries,         ,         .         .     190,  191 

maxilla,  upper, 47 

ovariotomy,     ......     171,  172 

tracheotomy, 80 

Structures  in  contact  with  ankle-joint, 277 

elbow-joint, 150 

hip-joint 240 

knee-joint,        ...  .263 

shoulder-joint, 126 

Subclavian  region, 92 

artery,     .         .  95,   96 

ligature  of,   .  ......       97 

Submaxillary  region,          .........       71 


INDEX.  299 


PAGE 

Submaxillary  gland, 72 

Supra-scapular  artery,       ........         97,   98 

Synovial  membranes  of  foot, 286 

wrist, 161 


Temporal  artery,        .         .         .         .         .         .         .          .         .         .15 

bone. 21 

Temporo-parietal  region.  .         .         .         .         .         .          .         .          .16 

maxillary  articulation,        ....          ...  59 

Tenotomy  of  sterno-mastoid, 92 

hamstrings,           ........  257 

for  club-foot, 281 

Teno-synovitis, 154 

Testicle 200 

Thoracica  suprema  artery, 135 

acrornialis,        .                  135 

alar, 135 

long, 135 

Thorax, 106 

relations  of  structures  in  superior  aperture  of,    .          .         .  104 

relations  of  contents  to  Avails  of, 106 

cavity 118 

Thymus  gland,  remains  of,         .         ...          ...          .80 

Thyroid  body, 80 

artery,  superior,           ........  78 

inferior,  .........  78 

vein,  inferior,       .                   . 80 

Thymoidea  iina  artery,      .........  99 

Tibial  anterior  artery 267 

posterior  artery, 269 

Toes, 286 

Tongue, 61 

Tonsil,  region  of,       ..........  51 

excision  of,   ..........  52 

abscess  of, 52 

Trachea, 80 

Tracheotomy, .  80 

Transversus  perinei  artery, 214 

muscle, 210 

Trephining, 18 


Ulnar  artery  in  forearm,    .          .         .         .         .         .         .         .         .155 

at  wrist 160 

Ureter, 188 

Urethra,  male, 217 

female, 222 

Urine,  extravasation  of, 199 


Varicocele, 200 

Varicose  aneurisms,  ..........     148 

Vas  deferens, 200 

Venesection,      ....  15,  148 


300  INDEX, 


PAGK 

Vein,  basilic, 140 

cephalic,  .         .         .         .         .         .         .         .         .         .140 

diploic 17 

jugular,  external,     .........       82 

internal, 85,  86 

median,  cephalic,     .........     147 

basilic, 147 

prseparata,       .  15 

saphena,  external,    .         .         .         .         .         .         .         .         .     256 

internal 248 

subclavian,  pulsation  in,  .......       93 

Vertebra,  dorsal, 117 

cervical,  .         .          .          .          .         .          .          .          .          .103 

lumbar 196 

Vertebral  artery, 103 

Vesicula  seminales, 227 

Vulva, 223 


Wrist,  region  of 157 

Wryneck, 92 


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of  374  pages,  extra  cloth,  $3. 

ERICHSEN  (JOHN).  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  and  improved  American,  from  the  sixth  enlarged  and  re- 
vised London  edition.  Illustrated  with  630  engravings  on  wood.  In 
two  large  8vo.  vols. ,  extra  cloth,  $9  00  ;  leather,  raised  bands,  $11  00. 

, ON  RAILWAY  AND  OTHER  INJURIES  OF  THE  NERVOUS 

SYSTEM.     In  one  small  8vo.  vol.,  extra  cloth,  $]. 

•PNCYCLOPJEDIA  OF  GEOGRAPHY.     In  three  large  8vo.  vols.     Illus- 
•*J    trated  with  83  maps  and  about  1100  wood-cuts,  cloth,  $5. 

FENWICK  (SAMUEL.)  THE  STUDENTS'  GUIDE  TO  MEDICAL 
DIAGNOSIS.  From  the  Third  Revised  and  Enlarged  London  Edi- 
tion. In  one  vol.  royal  12mo.,  with  numerous  illustrations.  (Now 
Ready.)  Extra  cloth,  $2  25. 

THISKE  FUND  PRIZE  ESSAYS  ON  TUBERCULOUS  DISEASE.     In 
J-      one  small  8vo.  vol.,  cloth,  $1. 

FLETCHER'S  NOTES  FROM  NINEVEH,  AND  TRAVELS  IN  MESO- 
POTAMIA,  ASSYRIA,  AND  SYRIA.  In  one  12mo.  vol.,  cloth,  75cts. 


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FOX  ON  DISEASES  OF  THE  STOMACH.  Publishing  in  the  Medi- 
cal News  and  Library  for  1873. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fourth  edition,  thoroughly  revised 
and  enlarged.  In  one  large  8vo.  volume  of  1070  pages,  extra  cloth, 
$6  j  leather,  raised  bands,  $7.  (Just  iss^led.) 

A  PRACTICAL  TREATISE,  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.  One  8vo.  vol.  of  596  pages,  cloth,  $450. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged. 
In  one  neat  8vo.  vol.  of  over  500  pages,  $4  00.  (Lately  if  sued.) 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY. 
From  the  tenth  enlarged  English 'edition.     In  one  royal  12mo.  vol.  of 
857  pages,  with  197  illustrations,  extra  cloth,  $2  75  ;  leather,  $3  25. 
PULLER  (HENRY).     ON   DISEASES  OF  THE   LUNGS  AND  AIR 
J-      PASSAGES.     Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.     From  the  second  English  edition.     In  one  8vo.  vol 
of  about  500  pages,  extra  cloth,  $3  50. 

GAXLOWAY  (EGBERT).  A  MANUAL  OF  QUALITATIVE  AN 
ALYSIS.  From  the  fifth  English  edition.  (Now  ready.}  In  one 
]2mo.  vol.,  extra  cloth,  $2  50. 

GLUGE  (GOTTLIEB).  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated  by  Joseph  Leidy,  M.D.,  Professor  of  Anatomy  in  the 
University  of  Pennsylvania,  &c.  In  one  vol.  imperial  quarto,  with 
320  copper  plate  figures,  plain  and  colored,  extra  cloth,  $4. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND 
MORBID  ANATOMY.  In  one  handsome  8vo.  vol.,  with  numerous 
illustrations.  (Just  issued.)  Extra  cloth,  $2  50. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SURGERY.  In  two  8vo. 
vols.  of  about  1000  pages,  leather,  $6  50. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
A  new  American,  from  the  fifth  and  enlarged  London  edition.  In  one 
large  imperial  8vo.  vol.  of  about  900  pages,  with  462  large  and 
elaborate  engravings  on  wood.  Cloth,  $6;  leather,  $7.  (Just  issued 

GRIFFITH    (ROBERT  E.)      A   UNIVERSAL  FORMULARY,    CON 
TAINING  THE  METHODS  OF  PREPARING  AND  ADMINISTER- 
ING OFFICINAL  AND  OTHER  MEDICINES.     In  one  large  8vo. 
vol.  of  650  pages,  double  columns,  extra  cloth,  $4;  leather,  $5. 

GROSS  (SAMUEL  D.)  A  SYSTEM  OF  SURGERY,  PATHOLOGICAL, 
DIAGNOSTIC,  THERAPEUTIC,  AND  OPERATIVE.  Illustrated 
by  1403  engravings.  Fifth  edition,  revised  and  improved.  In  two 
large  imperial  8vo.  vols.  of  over  2200  pages,  strongly  bound  in 
leather,  raised  bands.  (Lately  issued.)  $15. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 

AIR  PASSAGES.    In  one  8vo.  vol.  of  468  pages.    Extra  cloth,  $2  75. 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY.     Third  edition. 

In  one  large  8vo.  vol.  of  nearly  800  pages,  with  about  350  illustra- 
tions, extra  cloth,  $4. 

GUERSANT  (P.)  SURGICAL  DISEASES  OF  INFANTS  AND  CHIL- 
DREN. Translated  by  R.  J.  Dungliaon,  M.  D.  In  one  8vo.  vol., 
cloth,  $2  50. 

TJUDSON   (A.)     LECTURES  ON  THE  STUDY  OF  FEVER.     1  vol. 
•tl    8vo.,  316  pages   cloth,  $2  50. 


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HEATH  (CHRISTOPHER).  PRACTICAL  ANATOMY  ;  A  MANUAL 
OP  DISSECTIONS.  With  additions,  by  W.  W.  Keen,  M.  D.  In  1 
volume  ;  with  247  illustrations.  Cloth,  $3  50  ;  leather,  $4. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Third  and  revised  edition.  In 
one  12mo.  vol.  of  nearly  500  pages,  cloth,  $2  38;  half  bound,  $2  63. 

CONSPECTUS  OF  THE  MEDICAL   SCIENCES.      Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery,  and  Obstetrics.  In  one  royal  12mo.  vol- 
ume of  over  1000  pa-ges,  with  about  300  illustrations.  Strongly 
bound  in  leather,  $5  25  ;  extra  cloth,  $4  50. 

HAMILTON  (FRANK  H.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES AND  DISLOCATIONS.  Fourth  and  revised  edition. 
In  one  handsome  8vo.  vol.  of  789  pages,  and  322  illustrations. 
Extra  cloth,  $5  75;  leather,  $6  75. 

HOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMS  USED 
IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one 
12mo.  vol.  of  over  500  double  columned  pages,  cloth,  $1  50; 
leather,  $2. 

HODGE  (HUGH  L.)  ON  DISEASES  PECULIAR  TO  WOMEN,  IN- 
CLUDING DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.  In  one  8vo.  volume,  cloth,  $4  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  159  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large 
quarto  vol.  of  550  double-columned  pages.  Strongly  bound  in  extra 
cloth,  $14. 

HOLLAND  (SIR  HENRY).  MEDICAL  NOTES  AND  REFLECTIONS. 
From  the  third  English  edition.  In  one  8vo.  vol.  of  about  500  pages, 
extra  cloth,  $3  50. 

HODGES  (RICHARD  M.)    PRACTICAL  DISSECTIONS.    Second  edi- 
tion.    In  one  neat  royal  12mo.  vol.,  half  bound,  $2. 
HUGHES     SCRIPTURE    GEOGRAPHY    AND    HISTORY,   with    12 
colored  maps.    In  1  vol.  12mo.,  cloth,  $1. 

HORNER  (WILLIAM  E.)  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  revised  and  modified.  In  two  large  8vo.  vols.  of  over 
1000  pages,  containing  300  wood-cuts,  extra  cloth,  $6. 

HILL  (BERKELEY).     SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
ORDERS.    In  one  8vo.  volume  of  467  pages,  extra  cloth,  $3  25. 
SILLIER  (THOMAS).     HAND-BOOK  OF  SKIN  DISEASES.     Second 
Edition.     In  one  neat  royal  12mo.  volume,  about  300  pp.,  with  two 
plates,  cloth,  $2  25. 

HALL  (MRS.  M.)  LIVES  OF  THE  QUEENS  OF  ENGLAND  BEFORE 
THE  NORMAN  CONQUEST.  In  one  handsome  8vo.  vol.,  cloth, 
$2  25;  crimson  cloth,  $2  50;  half  morocco,  $3. 

TONES  (C.  HANDFIELB),  AND  SIEVEKING  (E.  B.  H.)     A  MANUAL 
O      OF  PATHOLOGICAL  ANATOMY.     In  one  large  8vo.  vol.  of  nearly 
750  pages,  with  397  illustrations,  extra  cloth,  $3  50. 

TONES  (C.  HANBFIELB).     CLINICAL  OBSERVATIONS  ON  FUNC- 
U      TIONAL  NERVOUS  DISORDERS.     Second  American  Edition.     In 
one  8vo.  vol.  of  348  pages,  extra  cloth,  $3  25. 

EIRKES  (WILLIAM  SENHOUSE)  A  MANUAL  OF  PHYSIOLOGY. 
A  new  American,  from  the  eighth  London  edition.  One  vol.,  with 
many  illus.,  12mo.  (Now  Ready.)  Cloth,  $3  25;  leather,  $2  75. 


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T7-NAPP  (F.)     TECHNOLOGY  ;  OR  CHEMISTRY,  APPLIED  TO  THE 
-»•*•    ARTS  AND  TO  MANUFACTURES,  with  American  additions,  by 

Prof.  Walter  R.  Johnson.     In  two  8vo.  vols.,  with  500  illustrations, 

cloth,  $6. 

T7"ENNEDY'S  MEMOIRS  OF  THE  LIFE  OF  WILLIAM  WIRT.     In 
-"•    two  vols.  12mo.,  cloth,  $2. 

LEA  (HENEY  C.)  SUPERSTITION  AND  FORCE ;  ESSAYS  ON  THE 
WAGER  OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL, 
AND  TORTURE.  Second  edition,  revised.  In  one  handsome  royal 
12mo.  vol.,  $2  75.  (Lately  issued.) 

STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  In  one  handsome 
12mo.  vol.  of  515  pp.,  extra  cloth,  $2  75.  (Lately  Issued.) 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 

IN  THE  CHRISTIAN  CHURCH.  In  one  handsome  octavo  volume 
of  602  pages,  extra  cloth,  $3  75. 

T  A  ROCHE  (E.)     YELLOW  FEVER  IN  ITS  HISTORICAL,  PATHO- 

-U  LOGICAL,  ETIOLOGICAL,  AND  THERAPEUTICAL  RELA- 
TIONS. In  two  8vo.  vols.  of  nearly  1500  pages,  extra  cloth,  $7. 

PNEUMONIA,  ITS  SUPPOSED  CONNECTION,  PATHOLO- 
GICAL AND  ETIOLOGICAL,  WITH  AUTUMNAL  FEVERS.  In 
one  8vo.  vol.  of  500  pages,  extra  cloth,  $3. 

TEISHMAN  (WILLIAM).    A  SYSTEM  OF  MIDWIFERY.     Includ- 
•Ll     ing  the  Diseases  of  Pregnancy  and  the  Puerperal  State.    In  one  large 

and  very  handsome  8vo.  vol.  of  700  pp.  and  182  ill  us.  (Nearly  ready.) 
T  ATJEENCE  (J.  Z.)  AND  MOON  (EOBEET  C.)  A  HANDY-BOOK 
•Ll  OF*  OPHTHALMIC  SURGERY.  Second  edition,  revised  by  Mr. 

Laurence.     With  numerous  illustrations.     In  one  8vo.  vol.,  extra 

cloth,  $2  75. 

T  EHMANN  (C.  G.)     PHYSIOLOGICAL  CHEMISTRY.    Translated  by 
-LI     George  F.  Day,  M.  D.     With  plates,  and  nearly  200  illustrations. 

In  two  large  8vo.  vols.,  containing  1200  pages,  extra  cloth,  $6. 
A    MANUAL  OF   CHEMICAL   PHYSIOLOGY.     In   one  very 

handsome  8vo.  vol.  of  336  pages,  extra  cloth,  $2  25. 

T  AWSON  (GEOEGE).   INJURIES  OF  THE  EYE,  ORBIT,  AND  EYE- 
•Ll     LIDS,  with  about  100  illustrations.     From  the  last  English  edition. 

In  one  handsome  8vo.  vol.,  extra  cloth,  $3  50. 

T  TJDLOW  (J.  L.)     A  MANUAL  OF  EXAMINATIONS  UPON  ANA- 
-U     TOMY,  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE, 

OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY, 

AND  THERAPEUTICS.     To  which  is  added  a  Medical  Formulary. 

Third  edition.     In  one  royal  12mo.  vol.  of  over  800   pages,    extra 

cloth,  $3  25  ;  leather,  $3  75. 

TYNCH  (W.  F.)     A  NARRATIVE  OF  THE  UNITED  STATES  EX. 
-LI     PEDITION  TO  THE  DEAD  SEA  AND  RIVER  JORDAN.     In  one 

large  and  handsome  octavo  vol.,  with  28  beautiful  plates  and  two 

maps,  cloth,  $3. 

•  Same  Work,  condensed  edition.     One  volume  royal  12mo.,  extra 

cloth,  $1. 

TAYCOCK    (THOMAS).    LECTURES   ON   THE   PRINCIPLES   AND 
-LI     METHODS  OF  MEDICAL  OBSERVATION  AND  RESEARCH.    In 

one  12mo.  vol.,  extra  cloth,  $1. 

LYONS  (EOBEET  D.)  A  TREATISE  ON  FEVER.  In  one  neat  8vo. 
vol.  of  362  pages,  extra  cloth,  $2  25. 


HENRY  C.  LEA'S  PUBLICATIONS. 


M 


M 
M 


ARSHALL  (JOHN).  OUTLINES  OF  PHYSIOLOGY  HUMAN 
AND  COMPARATIVE.  With  Additions  by  FHAXCIS  G  SMITH. 
M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  University  of 
Pennsylvania.  In  one  8vo.  volume  of  1026  pages,  with  122  illustra- 
tions. Strongly  bound  in  leather,  raised  bands,  $7  50  ;  extra  cloth 
$6  50. 

ACLISE  (JOSEPH).  SURGICAL  ANATOMY.  In  one  large  im- 
perial quarto  vol.,  with  68  splendid  plates,  beautifully  colored ;  con- 
taining 190  figures,  many  of  them  life  size,  extra  cloth,  $14. 

SIGS  (CHAS.  D.)  OBSTETRICS,  THE  SCIENCE  AND  THE  ART. 
Fifth  edition,  revised,  with  130  illustrations.  In  one  beautifully 
printed  8vo.  vol.  of  760  pages,  extra  cloth,  $5  50  ;  leather,  $6  50. 

—  WOMAN  :  HER  DISEASES  AND  THEIR  REMEDIES.  Fourth 
and  improved  edition.  In  one  large  8vo.  vol.  of  over  700  pages, 
extra  cloth,  $5  ;  leather,  $6. 

ON  THE  NATURE,  SIGN  S,  AND  TREATMENT  OF  CHILD-BED 


FEVER.     In  one  8vo.  vol.  of  365  pages,  extra  cloth,  $2. 
TWTILLER  (JAMES) .    PRINCIPLES  OF  SURGERY     Fourth  American, 
•*•"•  from  the  third  Edinburgh  edition.      In  one  large  8vo.  vol.  of  700 

pages,  with  240  illustrations,  extra  cloth,  $3  75. 
THE  PRACTICE  OF  SURGERY.     Fourth  American,  from   the 

last  Edinburgh  edition.     In  one  large  8vo.  vol.  of  700  pages,  with 

364  illustrations,  extra  cloth,  S3  75. 

TV/TONTGOMERY  (W.  F.)      AN  EXPOSITION  OF  THE  SIGNS  AND 
1V1  SYMPTOMS  OF  PREGNANCY.     From  the  second  English  edition. 
In  one  handsome  8vo.  vol.  of  nearly  600  pages,  extra  cloth,  $3  75. 

MORLAND  (W.  W.)  DISEASES  OF  THE  URINARY  ORGANS.  With 
illustrations.  In  one  handsome  8vo.  vol.  of  about  600  pages,  extra 
cloth,  $3  50. 

MORLAND  (W.  W.)  ON  THE  RETENTION  IN  THE  BLOOD  OF  THE 
ELEMENTS  OF  THE  URINARY  SECRETION.  In  one  vol.  8vo., 
extra  cloth,  75  cents. 

MULLEB  (J.)  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 
In  one  large  Svo.  vol.  with  550  wood-cuts,  and  two  colored  plates, 
cloth,  $4  50. 

MIRABEAU;  A  LIFE  HISTORY.  In  one  royal  12mo.  vol.,  cloth, 
75  cents. 

MACFAELAND'S  TURKEY  AND  ITS  DESTINY.  In  2  vols.  royal 
12mo.,  cloth,  $2. 

MARSH  (MRS.)  A  HISTORY  OF  THE  PROTESTANT  REFORMA- 
TION IN  FRANCE.  In  2  vols.  royal  12mo.,  extra  cloth,  $2. 

NELIGAN  (J.  MOOKE).  A  PRACTICAL  TREATISE  ON  DISEASES 
OF  THE  SKIN.  Fifth  American,  from  the  second  Dublin  edition. 
In  one  neat  royal  12ino.  vol.  of  462  pages,  extra  cloth,  $2  25. 

AN  ATLAS  OF  CUTANEOUS  DISEASES.     In  one  handsome 

quarto  vol.  with  beautifully  colored  plates,  &c.,  extra  cloth,  $5  50. 

BILL  (JOHN)  AND  SMITH  (FRANCIS  G.)  COMPENDIUM  OF 
THE  VARIOUS  BRANCHES  OF  MEDICAL  SCIENCE.  In  one 
handsome  12rno.  vol.  of  about  1000  pages,  with  374  wood-cuts, 
extra  cloth,  $4;  leather,  raised  bands,  $4  75. 

NIEBTJHR  (B.  G.)  LECTURES  ON  ANCIENT  HISTORY ;  com- 
prising the  history  of  the  Asiatic  Nations,  the  Egyptians, 
Greeks,  Macedonians,  and  Carthaganians.  Translated  by  Dr.  L. 
Schmitz.  In  three  neat  volumes,  crown  octavo,  cloth,  $5  00. 


N 


HENRY  C.  LEA'S  PUBLICATIONS.  9 


OBSTETRICAL  JOURNAL.  Edited  by  JAMES  H.  AVELINO,  M.D., 
and  ALFRED  WILTSHIRE,  M  D.  With  an  American  Supplement, 
edited  by  WILLIAM  F.  JENKS,  M.D.  $5  00  per  annum,  in  advance. 
Single  Numbers,  50  cents.  Is  published  monthly,  each  number  con- 
taining about  eighty  octavo  pages.  Commencing  with  April,  1873. 

ODLING  (WILLIAM).  A  COURSE  OF  PRACTICAL  CHEMISTRY 
FOR  THE  USE  OF  MEDICAL  STUDENTS.  From  the  fourth 
revised  London  edition.  In  one  12mo.  vol.  of  261  pp.,  with  75  illus- 
trations, extra  cloth,  $2.  (Lately  Issued.) 

PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION  : 
ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the  second 
London  Ed.  In  one  8vo.  vol.  of  246pp.,  ext.  cl.,  $2.  (Lately  Issued.) 

pARRISH  (EDWARD).    A  TREATISE  ON  PHARMACY.    With  many 
J-      Formula  and  Prescriptions.   Fourth  edition.    In  one  handsome  8vo. 
vol.      (In  preparation. ) 

pIRRIE  (WILLIAM) .    THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
-t      GERY.     In  one  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  extra  cloth,  $3  75. 

pEREIRA  (JONATHAN).     MATERIA  MEDIC  A  AND  THERAPEU- 
-*-      TICS.     An  abridged  edition.     With  numerous  additions  and  refe- 
rences to  the  United  States  Pharmacopoeia.      By  Horatio  C.   Wood, 
M.  D.     In  one  large  octavo  volume,  of  1040  pages,  with  236  illustra- 
tions, extra  cloth  $7  00 ;  leather,  raised  bands,  $8  00. 

pTJLSZKY'S  MEMOIRS  OF  AN  HUNGARIAN  LADY.     In   one  neat 
•t     royal  12mo.  vol.,  extra  cloth,  $1. 

PAGET'S  HUNGARY  AND  TRANSYLVANIA.  In  two  royal  12mo. 
vols.,  cloth,  $2. 

ROBERTS  (WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES.  A  second  American,  from  the  second 
London  edition.  With  numerous  illustrations  and  a  colored  plate. 
In  one  very  handsome  8vo.  vol.  of  616  pages.  Extra  cloth,  $4  50. 
(Just  Issued.) 

TDAMSBOTHAM   (FRANCIS   H.)     THE   PRINCIPLES  AND   PRAC- 
-tu    TICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY.     In  one  im- 
perial 8vo.  vol.  of  650  pages,  with  64  plates,  besides  numerous  wood- 
cuts in  the  text.     Strongly  bound  in  leather  $7. 

•DIGBY  (EDWARD).     A  SYSTEM  OF  MIDWIFERY.     Second  Ameri- 
•tw    can  edition.     In  one  handsome  8vo.  vol.  of  422  pages,  extra  cloth, 
$2  50. 

EANKE'S  HISTORY  OF  THE  TURKISH  AND  SPANISH  EMPIRES 
in  the  16th  and  beginning  of  17th  Century.  In  one  8vo.  volume, 
paper,  25  cts. 

HISTORY  OF  THE  REFORMATION  IN  GERMANY.     Parts  I. 

II.  III.     In  one  vol.,  extra  cloth,  $1. 

T)OYLE  (J.  FORBES).   MATERIA  MEDIC  A  AND  THERAPEUTICS. 
•»•«    Edited  by  Jos.  Carson,  M.  D.     In  one  large  8vo.  vol.  of  about  700 

pages,  with  98  illustrations,  extra  cloth,  $3. 

pADCLIFFE,   AINSTIE,  AND   OTHERS,  ON   DISEASES   OF   THE 
-LV'    SPINAL  COLUMN  AND  OF  THE  NERVES.     1  vol.  8vo.,  extra 

cloth.     $1  50. 

OMITH  (EUSTACE).  ON  THE  WASTING  DISEASES  OF  CHILDREN. 
*^     Second  American  edition,  enlarged.     In  one  8vo.  vol.,  extra  cloth. 
$2  50.     (Just  Issued.) 


10  HENRY  C.  LEA'S  PUBLICATIONS. 

SARGENT  (F.  W.)  ON  BANDAGING  AND  OTHER  OPERATIONS 
OF  MINOR  SURGERY.  New  edition,  with  an  additional  chapter 
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SLADE  (D.  D.)  DIPHTHERIA  ;  ITS  NATURE  AND  TREATMENT. 
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SMITH  (HENRY  H.)  AND  HORNER  (WILLIAM  E.)  ANATOMICAL 
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STILLE  (ALFRED) .  THERAPEUTICS  AND  MATERIA  MEDIC  A. 
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S WAYNE  (JOSEPH  GRIFFITHS).  OBSTETRIC  APHORISMS.  A 
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HENRY  C.  LEA'S  PUBLICATIONS.  11 

STTJRGES  (OCTAVITTS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  In  one  12mo.  vol.,  extra  cloth,  $1  25. 
(Now  Ready.) 

SCHOEDLER  (FREDERICK)  AND  MEDLOCK  (HENRY).  WONDERS 
OF  NATURE.  An  elementary  introduction  to  the  Sciences  of  Physics, 
Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zoology, 
and  Physiology.  Translated  from  the  German  by  H.  Medlock.  In 
one  neat  8vo.  vol.,  with  679  illustrations,  extra  cloth,  $3. 

SMALL  BOOKS  ON  GREAT  SUBJECTS.  Twelve  works ;  each  one  10 
cents,  sewed,  forming  a  neat  and  cheap  series  ;  or  done  up  in  3  vols., 
extra  cloth,  $1  50. 

QTRICKLAND    (AGNES).     LIVES  OF  THE  QUEENS   OF   HENRY 
»3     THE  VIII.  AND  OF  HIS   MOTHER.     In  one  crown  octavo  vol., 
extra  cloth,  $1 ;  black  cloth,  90  cents. 

MEMOIRS  OF  ELIZABETH,  SECOND  QUEEN  REGNANT  OF 

ENGLAND  AND  IRELAND.  In  one  crown  octavo  vol.,  extra  cloth, 
$140;  black  cloth,  $1  30. 

rpANNER  (THOMAS  HAWKES).    A  MANUAL  OF  CLINICAL  MEDI- 

-L     CINE  AND   PHYSICAL   DIAGNOSIS.     Third  American  from  the 

second  revised  English  edition.     Edited  by  Tilbury  Fox,  M.  D.     In 

one  handsome  12mo.  vol.  of  366pp.,  cloth,  $1  50.    (Lately  published.) 

ON  THE   SIGNS  AND  DISEASES  OF  PREGNANCY.     First 

American  from  the  second  English  edition.  With  four  colored  plates 
and  numerous  illustrations  on  wood.  In  one  vol.  8vo.  of  about  500 
pages,  extra  cloth,  $4  25. 

rpUKE  (DANIEL  HACK).     INFLUENCE  OF  THE  MIND  UPON  THE 
•»•     BODY.     In  one  handsome  8vo.  vol.  of  416  pp.,  extra  cloth,  $3  25. 

(Now  Ready.) 

rpAYLOR    (ALFRED    S.)     MEDICAL    JURISPRUDENCE.     Seventh 
-*•     American  edition.     Edited  by  John  J.  Reese,  M.D.     In  one  large 

8vo.  volume  of  879  pp.     Extra  cloth,  $5  00  :  leather,  $6  00. 
PRINCIPLES  AND   PRACTICE   OF    MEDICAL   JURISPRU- 
DENCE.    From  the  Second  English  Edition.      In  two  large  8vo. 
vols.      (Jicst  ready.) 

-  ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 
JURISPRUDENCE.  Third  American  from  the  Third  London  Edi- 
tion. 1  vol.  8vo.  (Preparing.) 

rpHOMAS  (T.  GAILLA.RD).    A   PRACTICAL  TREATISE  ON   THE 
-L     DISEASES  OF  FEMALES.     Third  and  enlarged  edition.     In  one 
large  and  handsome  octavo  volume  of  784  pages,   with  about  250 
illustrations.      Extra  cloth,  $5  00 ;     leather,  $6  00. 

TODD  (ROBERT  BENTLEY) .  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  vol.  8vo.  of  320  pp.,  extra  cloth,  $2  50. 

rnHOMPSON  (SIR  HENRY).    CLINICAL  LECTURES  ON  DISEASES 

-L     OF  THE  URINARY  ORGANS.     In  one  8vo.  volume  of  204  pages, 
with  illustrations,  extra  cloth,  $2  25. 

THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULJE.  From  the  third 
English  edition.  In  one  8vo.  vol.  of  359  pp.,  with  illustrations,  extra 
cloth,  $3  50. 

THE  DISEASES  OF  THE  PROSTATE,  THEIR  PATHOLOGY 

AND  TREATMENT.  Fourth  edition,  revised.  In  one  very  hand- 
some 8vo.  vol.  of  355  pp.,  with  13  plates.  Extra  cloth,  $3  75. 
ALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  THE  HEART  AND  GREAT  VESSELS.  Third  American  from 
the  third  revised  London  edition.  la  one  8vo.  vol.  of  420  pages, 
extra  cloth,  $3. 


W 


12  HENRY  C.  LEA'S  PUBLICATIONS. 

WOHLEB'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  8th  German  edition,  by  Ira  Remsen,  M.D.  In  one  neat 
12mo.  vol.,  extra  cloth,  $3  00.  (Lately  issued.) 

WALES  (PHILIP  S.)  MECHANICAL  THERAPEUTICS.  In  one 
large  8vo.  vol.  of  about  700  pages,  with  642  illustrations  on  wood, 
extra  cloth,  $5  75 ;  leather,  $6  75. 

WELLS  (J.  SOELBEKG).  A  TREATISE  ON  THE  DISEASES  OF 
THE  EYE.  Second  American,  from  the  Third  English  edition,  with 
additions  by  I.  Minis  Hays,  M.D.  In  one  large  and  handsoine  octavo 
vol.,  with  6  colored  plates  and  many  wood-cuts,  also  selections  from 
the  test-types  of  Jaeger  and  Snellen.  Cloth,  $5  00  j  leather,  $6  00. 
(Now  ready.) 

WHAT  TO   OBSERVE  AT  THE   BEDSIDE  AND  AFTER  DEATH 
W  IN  MEDICAL  CASES.    In  one  royal  12mo.  vol.,  extra  cloth,  $1. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and  en- 
larged  English  edition,  with  additions  by  H.  Hartshorne,  M.D.  In 
two  large  and  handsome  octavo  volumes.  (Now  Ready.)  Extra 
cloth,  $9  ;  leather,  $11. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  Third  English  edition.  In 
one  octavo  volume  of  550  pages,  extra  cloth,  $3  75  ;  leather,  $4  75. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  English  edition.  In 
one  large  8vo.  vol.  of  656  closely  printed  pages,  extra  cloth,  $4  50  ; 
leather,  $5  50. 

ON   SOME   DISORDERS    OF    THE   NERVOUS   SYSTEM   IN 

CHILDHOOD.     From  the  London   Edition.     In  one   small  12mo. 
volume,  extra  cloth,  $1.     (Now  ready.) 

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE 

OF  ULCERATION  OF  THE  OS  UTERI.     In  one  vol.  8™.,  extra 
cloth,  $1  25. 

WILLIAMS  (CHAELES  J.  B.)  PULMONARY  CONSUMPTION: 
ITS  NATURE,  VARIETIES,  AND  TREATMENT.  In  one  neat 
octavo  volume.  Cloth,  $2  50.  (Now  ready.) 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A 
new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings  on  wood.  In  one  handsome  8vo.  vol.  of  over 
600  pages,  extra  cloth,  $4  ;  leather,  $5. 

ON  DISEASES  OF  THE  SKIN.     The  seventh  American  from 

the  last  English  edition.     In  one  large  8vo.  vol.  of  over  800  pages, 
extra  cloth,  $5. 

Also,  A  SERIES  OF  PLATES,  illustrating  "Wilson  on  Diseases  of  the 
Skin,"  consisting  of  20  plates,  thirteen  of  which  are  beautifully 
colored,  representing  about  one  hundred  varieties  of  Disease.  $5  50. 

Also,  the  TEXT  AND  PLATES,  bound  in  one  volume,  extra  cloth,  $10. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.    In 

one  handsome  royal  12mo.  vol.,  extra  cloth,  $3  50. 

WINSLOW  (FORBES).  ON  OBSCURE  DISEASES  OF  THE  BRAIN 
AND  DISORDERS  OF  THE  MIND.  In  one  handsome  8vo.  vol. 
of  nearly  600  pages,  extra  cloth,  $4  25. 

TTn-INCKEL  ON   DISEASES   OF   CHILDBED.     Translated  by  Chad- 
*•    wick.     (Preparing.) 

^EISSL     ON    VENEREAL     DISEASES.       Translated    by    Sturgis. 
"   ( Prepa ri ng.) 


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